Team Member (Full Name):

                                                 ____________________________________________________________

Email address: _______________________________________________________

Address:           ___________________________________________________________________

City, State, Zip ___________________________________________________________________

Home Phone: ____________________________ Business Phone: __________________________

Birth date: _____________________ Age: ______  Gender: ________

Emergency Contact -- Name: _____________________________________ Relationship to You: __________________

________________________________________________________________________________________________________

Medical Information

Your (REAL) height:  ____________  Your (REAL) weight: ____________

Blood Type: ________________ Do you wear contact lenses? _____________

If you have any questions regarding your participation in an adventure race, then please discuss them with your physician.

Do you have (circle):

YES NO   Allergies (including medications, foods, and/or insect bites)? Please list:

_________________________________________________________________________________________

If allergic to bee stings, do you carry medication?  ____    What medication? ___________________________________________________________________________________________

YES NO   Heart Disease?

YES NO   Diabetes?

YES NO   Chest pain with physical exertion?

YES NO   High blood pressure?

YES NO   Epilepsy?

YES NO   Asthma?

YES NO   Do you smoke?

YES NO   Back problems? Please explain: __________________________________________________________________

YES NO   Dislocations? Please explain: ____________________________________________________________________

YES NO   Are you pregnant? How many months? ___________

YES NO   Have you ever had a heart attack or stroke? Please explain: __________________________________________

YES NO   Are you currently under a doctor’s care? Please explain: _____________________________________________

YES NO   Are you taking any medication? What type/what for? _______________________________________________

Describe your health: ____________________________________________________________________________________

________________________________________________________________________________________________________

Describe any medical condition, special consideration, or limitation, which might affect your health, participation, or the well being of others. ___________________________________________________________________________________

_________________________________________________________________________________________________________

I hereby state that I am medically fit and properly trained to participate in a challenging endurance contest such as this Performance Adventure Racing event. I have read and understand the concepts of this event and its rules and requirements. I am taking responsibility for my medical condition and preparation and do not hold any race manager, race director, volunteer, sponsor, or medical staff responsible for my condition or the outcome of my participation in this event.