Essential Eligibility Criteria (EEC) / Medical Self-Evaluation Form / Insurance Waiver / Release of Liability Waver & Media Release Form Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastName *FirstMiddleLastEmailHeight *Weight *Date of Birth *Can you seal your airway passage while under water? *YesNoPartlyI Don't KnowDo you require any type of external neck support *YesNoPartlyI Don't KnowAre you able to wear a properly fit life jacket (PFD) *YesNoPartlyI Don't KnowPlease describe your swimming ability: *Please describe your canoeing / kayaking / rafting / other paddlesports experience. *Allergies? *YesNoHeart Disease? *YesNoHigh Blood Pressure? *YesNoDislocations? *YesNoDo you get cold easly? *YesNoAllergic to insect bites or stings? *YesNoDiabetes? *YesNoAsthma? *YesNoAre you pregnant? *YesNoAllergic to any medications? *YesNoBack Problems? *YesNoMuscle spasms? *YesNoAre you greatly affected by heat? *YesNoAre you taking medications? *YesNoAny side effects of medication such as sun sensitivity, increased thirst or fatigue? *YesNoIf you answered YES to any of the questions above please explain below:Do you have a disability? If yes, please describe:Do you have mobility impairment? If yes, please describe:Do you have sensory impairment (sight, sounds or sensation)? If yes, please describe:So that we can better understand your needs, please list any medical, physical, physical, psychological or emotional issues not mentioned above:In case of Emergency - Please contact: *FirstLastDay Phone# *Other Number:Relation:Name *FirstMiddleLastParticipant/Volunteer's Name *FirstLastPhone Number: *Email:Date of Birth: *Male/Female *MaleFemaleHeight: *Weight: *Emergency Contact: *Emergency Contact Phone: *Participant Name *FirstMiddleLastParent/Guardian's NameFirstMiddleLastName *FirstMiddleLastEnter Today's Date: MM/DD/YYYY *NameSubmit