Please identify the specific expedition you are registering for (listed in calendar order):
*
March 14 - 29. Rio Futaleufu - Patagonia, Chile.
May 23 - 29. Desolation Canyon, Utah. Middle School.
May 29 - June 4. Desolation Canyon, Utah. Middle School.
June 6 - 12. Desolation Canyon, Utah. Middle School.
June 14 - 20. Wild & Scenic Rogue, Oregon. High School.
June 20 - 25. The Yampa River. Family Expedition.
June 21 - 28. Wild & Scenic Rogue, Oregon. Middle School.
June 30 - July 7. Cataract Canyon, Utah. High School.
July 13 - July 19. Cataract Canyon, Utah. High School.
July 13 - 16. Ruby Canyon, CO/UT. Elementary School.
July 15 - 22. Main Salmon River, Idaho. High School.
July 15 - 20. Lodore Canyon, CO/UT. Middle School.
July 20 - 23. Ruby Canyon, CO/UT. Elementary School.
July 27 - 30. Ruby Canyon, CO/UT. Elementary School.
August 3 - 6. Ruby Canyon, CO/UT. Elementary School.
August TBD - Rio Maranon, Peru.
September 9 - 12. Westwater Canyon, UT. Middle School.
Participant's Name:
*
First Name
Last Name
Name of the school you attend:
*
Participant's Date of Birth:
*
MM
DD
YYYY
Age (at the time of expedition launch):
*
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25+
Gender:
*
Female
Male
Height:
*
4' 0"
4' 1"
4' 2"
4' 3"
4' 4"
4' 5"
4' 6"
4' 7"
4' 8"
4' 9"
4' 10"
4' 11"
5' 0"
5' 1"
5' 2"
5' 3"
5' 4"
5' 5"
5' 6"
5' 7"
5' 8"
5' 9"
5' 10"
5' 11"
6' 0"
6' 1"
6' 2"
6' 3"
6' 4"
6' 5"
6' 6"
Weight (lbs):
*
Under 80
81 - 100
101 - 120
121 - 140
141 - 160
161 - 180
181 - 200
201 - 220
221 - 240
241 - 260
261 - 280
281 - 300
Over 300
T-shirt size (men's shirt)
*
XS
S
M
L
XL
XXL
How many previous GOALS expeditions have you participated in?
*
0
1
2
3
4
5
6+
Participant email address (can be left blank if the participant does not have an email address):
Participant cell phone (can be left blank if the participant does not have a cell phone):
(###)
###
####
Participant mailing address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent / guardian #1:
*
First Name
Last Name
Parent / guardian #1 - email address:
*
Parent / guardian #1 - cell phone:
*
(###)
###
####
Parent / guardian #2:
First Name
Last Name
Parent / guardian #2 - email address:
Parent / guardian #2 - cell phone:
(###)
###
####
Emergency contact #1:
*
First Name
Last Name
Please briefly describe the relationship of emergency contact #1 to the participant.
*
Emergency contact #1 - cell phone:
*
(###)
###
####
Emergency contact #2:
First Name
Last Name
Emergency contact #2 - cell phone:
(###)
###
####
Please list and briefly describe all PAST medical conditions / diagnoses that our guides and leaders should be aware of. This information will not be shared with anyone who is not directly involved in the supervisory care of the participant.
*
Please list and briefly describe all CURRENT medical conditions / diagnoses that our guides and leaders should be aware of. This information will not be shared with anyone who is not directly involved in the supervisory care of the participant.
*
Please list and briefly describe all prescription medications currently being taken by this participant. Include the reason each medicine is prescribed.
*
Please list and briefly describe any physical / activity restrictions for this participant.
*
Please list all non food-related allergies that this participant has, and describe their severity.
*
Are there any physical or mental health conditions / concerns not addressed in the previous questions that GOALS should be aware of?
*
Does this participant have any food allergies or intolerances we should account for when creating menus and food packing? If so, please list each and describe their severity.
*
Aside from the allergies described previously, does this participant have any dietary restrictions / preferences we should account for when creating menus and food packing? (This might include vegetarian, gluten free, etc.)
*
Participant's primary care physician:
First Name
Last Name
Primary care physician phone number:
(###)
###
####
Insurance company:
Name of policy holder:
Policy number:
Group number:
Insurance company phone number:
(###)
###
####
Please type your full name exactly as it appears on your passport.
Passport Number:
Passport Date of Issue:
Passport Date of Expiry:
