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Participant Information (SPI Assessment)

"*" indicates required fields

First Name*

Last Name*

Preferred Pronouns*

Date of Program*

Email Address*

Phone Number*

Course Code from AMGA Website*

Medical Information

Emergency Contact*

Relationship to Emergency Contact*

Emergency Contact Phone Number*

Do you have diabetes?*

How well is it under control?

Do you have a history of seizures?*

How well are they under control?

Do you have heart disease?*

How well is it managed?

Do you have a history of or currently have asthma?*

If you use an inhaler, will you have it with you?

Do you have a history of anaphylaxis or allergies?*

If so, will you have an EpiPen or other prescribed medications with you?

Do you have relevant musculoskeletal injuries or related surgeries? If so, please explain.

Do you have problems with vision or hearing? If so, please explain.

Do you have any other health issues that would prevent you from fully participating in activities provided by Vertical Voyages?*

If so, please explain.

Are you under the influence of illegal drugs or alcohol?*

Do you have medical insurance?*

If so, who is your provider?

Equipment Needs

Do you have a harness?*

If no, what is your waist size?

Do you have climbing shoes?*

If no, what is your shoe size?

Do you have a helmet?*

What additional gear, if any, do you own?

Climbing Experience

How long have you been climbing?*

What is your sport climbing lead grade?*

What is your trad climbing lead grade?*

Approximately how many trad lines have you led?*

Do you have a current first aid certification (CPR, WFA, WRF)?*

Why are you pursuing SPI Certification?*

Name

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Participant Information (SPI Assessment)

Medical Information

Equipment Needs

Climbing Experience

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