Participant Form

During a First Descents Program, participants will have the opportunity to partake in various activities. These activities can be strenuous and will occur in the outdoors away from immediate medical care. The risk of participation is increased by certain physical and mental conditions. Thus, it is important to screen every applicant for such conditions.

The purpose of this Participant Form is to provide the First Descents staff with a comprehensive understanding of your current medical condition. Your responses regarding your own medical fitness for participation in the First Descents Program described below (the “Program"), is requested to help the First Descents team provide you with an enjoyable and safe Program.

Please answer the following questions as thoroughly and accurately as possible. If you are not currently experiencing any of the conditions referenced herein, but your medical condition subsequently changes and includes any of the conditions referenced in this Participant Form or in the Participant Form Release Policies, attached hereto, please advise First Descents immediately. It is your responsibility to ensure that the content of this Participant Form is accurate and complete at all times prior to the Program and during the Program.

You must complete and sign this Participant Form in order to participate in the Program. A positive response to a question does not necessarily disqualify you from participating. Rather, the First Descents Medical Review Team will make a determination, based on the information in this Participant Form and the Doctor Form as to whether or not you are approved to participate in the Program.

If you have any additional questions regarding this Participant Form, please review this form with your physician before submitting to First Descents. For additional information regarding First Descents Program policies and procedures, please review the First Descents Policies attached.

Pre Program Health Agreement

First Descents (FD) Participants, Staff, and Volunteers should adhere to FD’s health principles and application requirements in order to attend a program. It is everyone’s personal responsibility to review these guidelines and adhere to them in order to ensure the safety and health of everyone at a program.

Pre-Program General Principles

Complete all paperwork in a timely and honest manner.
Inform the Programs Team of any changes to your health condition leading up to a program.
COVID-19 vaccinations are not required at this time to attend a program. However, program control measures must be followed at all times whether you have been vaccinated or not.
Arrive at a program healthy. Please do not come if you’re feeling unwell or sick, including showing symptoms of COVID-19 or other illness. Arriving at a program sick, or potentially being contagious, puts others at risk and can spread illness.
Eat well and hydrate in advance of the program.
Everyone may l be asked to transport themselves in their personal vehicles to and from the program and activity site. If carpooling, masking must be utilized.
Fatigue plays a part in both injuries and illnesses and a FD program is a very busy and exciting experience! Be sure to get enough rest leading up to a program so you can enjoy the program and stay healthy and safe.
If you require special accommodations (e.g. gear, dietary restrictions, sleeping needs, allergies, etc.) please inform the Programs Team well in advance of the program start date.
Check the weather before you pack and bring what you will need, including clothes and shoes appropriate for outdoor activities, as well as spending time as a group relaxing, and enjoying meals.. FD’s Packing List for your specific program activity will be emailed to you.
Please bring at least two (2) face masks and hand sanitizer with you.
The CDC encourages anyone who has traveled internationally to stay home, monitor their health and practice social distancing for 14 days after returning from travel. As a result, please do not attend a program within 14 days of international travel.

At-Program Principles

Come prepared to complete a COVID-19 screening at the beginning of the program, including a temperature check, and exposure and symptom screening led by FD staff or a volunteer. Everyone must complete the screening to be admitted to the program.
Adhere to FD’s program control measures at all times, including:

Hand Hygiene
Respiratory Etiquette
Face Covering and Use of Masks
Cleaning and Disinfection
Social Distancing
Follow Transportation Protocol (e.g.use of personal vehicle when appropriate)

Please turn your cell phones off and leave them in your cars and/or rooms. Cell phones often collect germs and can spread illness. Additionally, FD programs are technology-free. This is a once-in-a-lifetime opportunity for you to unplug and connect in a meaningful way with yourself and others for a short period of time.
Please come alone. Do not bring your family, friends and/or beloved pets unless you have been instructed otherwise by the Programs Team.
Do not share personal belongings, including drinks, shared food utensils and containers, hair brushes, pillows, toothbrushes, etc.
Do not leave the program at any time. If you leave the program, you will not be readmitted.
If you notice a change in your health, please report to a FD Staff member immediately. You may be asked to isolate from the group until your symptoms can be verified.
Communicate any questions, concerns, or observations to FD Staff directly.
In the event of a suspected communicable disease case, medical advice will be sought and communicable disease prevention protocols implemented.

FD’s Application Process

In light of COVID-19 and in order to keep everyone safe and healthy, FD’s program application process includes:

A general medical application including FD policies, biographical information, medical history, screening for high risk factors as outlined by the CDC, and exposure to COVID-19, etc.
A Physician’s Authorization for individuals with any high-risk factors, as outlined by CDC.
Follow up emails to screen for illness and exposure to COVID-19.
On-site screening for COVID-19 symptoms, exposure, and a temperature check. This is a CDC recommendation for any outdoor programs and will be conducted for everyone even if they have received the COVID-19 vaccination (the COVID-19 vaccine is not 100% effective).
Additionally, Lead Staff and/or Medical Volunteer will be conducting daily COVID-19 symptom tracking each program day. For overnight programs, the FD team will conduct daily medical observations related to COVID-19 symptoms.

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person. First Descents has put in place preventative measures to reduce the spread of COVID-19; however, First Descents cannot guarantee that you will not become infected with COVID-19. Further, participation in a First Descents program could increase your risk of contracting COVID-19.

All program participants and volunteers will be required to sign First Descents’ Release of Liability and Waiver of Legal Rights ahead of each program in order to be allowed admittance. Note: The public health situation and pandemic is constantly changing,FD may need to make changes to the application process as new information becomes available. If FD makes changes to the application or requirements you will be notified.

I understand and agree all of the information provided in the Pre Program Health Agreement Above

This Registration Form is for the MS Multi-Day Whitewater Kayaking Program, on July 23-25, 2021 in Charlemont, MA.

Completing this registration does not guarantee you a spot on this program. We will leave registration open for a week and will let you know the next steps if you're selected.

First Descents Policies

Please select the response that best applies to your program registration (note: please refer to our program information page for details and please review our MS program eligibility criteria HERE.)

VOLUNTEER MEDICAL AUTHORIZATION STATEMENT & CONSENT:

This Volunteer Application, together with First Descents release policies, are a statement in which you are informed of some potential risks involved in participating in an FD Program and of the conduct required of you before, during, and after a Program. You must complete this Medical Authorization Statement and Consent, which includes the Volunteer Form, in order to be accepted as a FD volunteer.

First Descents requires disclosure of certain medical information for all of its Participants and Volunteers. The purpose of this information will be used strictly to ensure a safe and enjoyable experience for all Program attendees. Because of this, First Descents may disclose medical information provided by its Participants and Volunteers to First Descents Staff, Medical Reviewers, Medical Volunteers, Contract Outfitters, and, in the event of an emergency, local medical facilities and Participant/Volunteer’s Emergency Contacts. Your information will otherwise remain confidential. You may obtain a copy of this authorization for your records if you choose.

Additional First Descents Volunteer Policies

First Descents believes in creating a welcoming and safe environment for Participants, Volunteers, Staff, Outfitters and Visitors. All Participants, Staff, Outfitters, Volunteers and Visitors are prohibited from possessing or consuming illicit drugs, recreational marijuana, weapons/contraband, and offensive material (pornography) while at a Program. They are also banned from sharing any prescription medication with others. If Participants and/or Volunteers are prescribed medical marijuana as part of their treatment plan (or for other reasons), First Descents will not prevent the individual from possessing and consuming medically prescribed marijuana. At all times, local and state laws will be applicable and at no time, do FD’s policies supersede local, state, and/or federal laws. At no time under any circumstances will a Participant or Volunteer be allowed to share their medication and/or medical marijuana with another individual.

Participants are prohibited from possessing or consuming alcohol at any time while at Programs. Staff, Volunteers and Visitors are barred from consuming alcohol in the company of Participants between the start and end date of the day’s planned activities. Light alcoholic consumption is allowed at the Staff and Volunteer Dinner the night before Participants arrive. Staff and Volunteers must exercise discretion and maintain a blood alcohol content (BAC) below the legal limit for driving. While Participants are present, Staff, Volunteers and Visitors may consume light amounts of alcohol at the completion of the day in privacy away from Participants. However, there must be a designated driver (among FD’s approved drivers, including Volunteers) assigned each night, who consumes no alcohol in the event of an emergency. Light alcohol consumption is defined as maintaining a blood alcohol content below the legal driving limit.

Notice to the Volunteer

First Descents Programs encourage self reliance, independence and good judgment throughout the duration of the Program. Consequently, everyone must be expected to administer their own medications without supervision. Additionally, any over-the-counter medications that anyone might require, including Participants, should be brought and self-administered (i.e. pain medications for minor aches such as Tylenol, Ibuprofen and/or allergy medicines).

Emergency Medical Care Authorization

I hereby authorize the Medical Director of First Descents or such designee or designees as the Medical Director may appoint, including pre-hospital providers, nurses, mid-level providers or physicians, First Descents medical volunteers, as well as any such medical personnel who are members or affiliates of First Descents' partnering outfitting and guide companies, ("Medical Personnel") to provide both basic and emergency medical care and treatment, in accordance with standard medical practice and/or established protocols, during (including to and from) the Program Initial Here

I am aware that there may be limits to the medical and legal liability of the Medical Personnel, as outlined in the RELEASE OF LIABILITY AND WAIVER OF LEGAL RIGHTS and I consider this notification of any such liability limitations that may exist under applicable state and federal law. Initial Here

I understand that information pertaining to my medical history or participation in the Program may be shared with and/or released to appropriate Medical Personnel for the purpose of medical review, treatment, supervision, or data collection pertinent to First Descents operations and data analysis (including, but not limited to First Descents staff, referral centers and/or insurance companies). I further understand that First Descents will keep this information on file indefinitely for my potential future participation in a First Descents Program, unless I request, in writing that my medical information be destroyed. Initial Here

APPLICANT'S MEDICAL AUTHORIZATION STATEMENT & CONSENT:

This PARTICIPANT FORM, together with the FIRST DESCENTS RELEASE POLICIES, are a statement in which you are informed of some potential risks involved in participating in the Program and of the conduct required of you before, during and after the Program. You must complete this Applicant’s Medical Authorization Statement and Consent, which includes the Participant Form section, to be accepted to the Program.

First Descents Programs encourage self reliance, independence and good judgment on/off the river/mountain. Consequently First Descents encourages everyone to be observant and to immediately bring forth any concerns about their own or a Participant’s medical conditions to the staff. Everyone, including Volunteers and Participants, are expected to self-administer their own medications without supervision.

Finally, certain medical conditions can pose additional risk to First Descents Volunteers, Staff, Outfitters and Participants. These include but are not limited to: seizures/syncope, physical disabilities, and the use of anticoagulation medication. Such conditions add an increased but unquantifiable risk to activities during the Program and anyone with those conditions, regardless of role, should discuss those conditions with their personal physician, as well as contact and communicate those conditions and any questions or concerts to First Descents.

I agree that I will notify First Descents in the event of any change in my medical condition, medications or allergies that might impact my ability to volunteer at a FD Program, from the time of submitting my initial Volunteer Form to the time of my actual participation at a Program as a volunteer. Initial Here

I understand that FD Medical personnel, as defined below, may contact my medical providers, or those individuals designated as “Emergency Contacts” herein, in the event of a medical emergency or urgency, including any notifications of medical providers or other appropriate authorities in regard to statements or actions suggestive of severe mental illness or intent for harming or injuring myself or others. Initial Here

I certify that I am eighteen (18) years of age or older, that I have read and fully understand this Medical Authorization Statement and Consent, and that I freely and voluntarily agree to be legally bound by the terms of this Medical Authorization Statement and Consent. Initial Here

I understand that I may revoke this authorization at any time in writing by sending a letter to First Descents. Revoking this authorization will prohibit disclosure of my personal health information by First Descents; but such revocation will not affect information that has already been disclosed by First Descents to Medical Personnel. To revoke this Authorization, please submit a written request to Attn: First Descents Programs Team; 3858 Walnut Street Suite 161, Denver, CO 80205. Initial Here

Signature

Date of Signature

Personal Info

Personal and Contact Information

Email Address

Confirm Email Address

First Name

Last Name

What is your Date of Birth? (MM/DD/YYYY)

Street Address

Address Line 2

City

State/Province/Region

Postal/Zip Code

Home Phone

Mobile Phone

T-shirt size

How do you identify your gender?

How do you self identify?

What ethnicity/race do you identify as?

What are your preferred pronouns? (he/him, she/her, they/them) Feel free to leave this blank if you prefer

Marital status

Do you have children?

Are you currently working?

Are you a veteran?

Emergency Contacts

Please list two emergency contacts that are reliable and available that FD can reach out to to provide support in the event of an emergency.

Emergency Contact #1

Name

Relationship

Home Phone

Work Phone

Mobile phone

Emergency Contact #2

Name

Relationship

Home phone

Work phone

Mobile phone

Medical Information

GENERAL MEDICAL

Weight

Height

Shoe Size (for rental gear you will use)

Do any of the following apply to you (select all that apply)

Cardiac/Heart Conditions (e.g. Heart Attack, Heart Failure, Arrhythmia, etc.) Chronic Lung Disease (e.g. Asthma, COPD, Pulmonary Fibrosis, etc.)DiabetesFrequent (daily) vomiting or diarrhea that may affect participation (e.g. Crohn's, Colitis, etc.)Liver Failure Current Ileostomy/ColostomyRenal Failure/DialysisNone of these apply to me

Please Explain

Do you have or use any of the following? (select all that apply)

Pacemaker or Automated Implantable Cardioverter Defibrillator (AICD)Port-a-cath or access portInsulin PumpVentriculo-Peritoneal ShuntRequire Continuous Positive Airway Pressure (CPAP) or Oxygen TherapyRequire a Colostomy BagNeed to frequently use Urinary CatheterNone of these apply to me

Please Explain

NEUROLOGICAL

Have you ever felt dizzy, disequilibrium, or like the world is spinning?

If you have felt dizzy, disequilibrium, please explain. Please also include if this is something you are currently experiencing

Have you ever had a seizure or other episode of lapse or loss of consciousness (e.g passing out/ syncope)?

Because symptoms vary so greatly, we would love to have a clear understanding of warning signs for us to look for at your Program. Can you describe potential causes of your seizures/ lapses of consciousness as well as symptoms you may experience during an episode, especially as they relate to your mental consciousness and level of motor control?

Not all seizures affect a person's motor control and consciousness. If you were having one of your typical seizures, would you be able to reach the ground, pick up a gallon of water, and walk away with it?

YesNo

When was your last seizure or episode of lapse of consciousness?

Less than 3 months ago3-6 months ago6 months to 1 year agoGreater than 1 year ago

How often do you have seizures or lapses of consciousness?

About once a week or greaterAbout once a monthAbout once a yearI have only had one seizure

Are you medically cleared to drive?

YesNo

Do you have Multiple Sclerosis (MS)?

What type of MS do you have?

Please review our MS program eligibility criteria HERE. List any MS symptoms you have or that sometimes occur during stressful situations

Do you have frequent migraines?

Do you have a history of traumatic brain injury?

Please Explain

Have you ever had a Stroke?

Neurologist, Specialist, or Physician Info

(Whoever you see the most frequently)

Name

Hospital/Institution

Street Address

City

State/Province/Region

Postal/Zip Code

Office Phone

Emergency Phone

Additional Team Info

Do you see a Social Worker?

Social Worker Name

Social Worker Phone

Social Worker Email

PSYCHIATRIC

First Descents strives to create a safe place for our participants physically and from a mental health perspective. We understand the stigmas that sometimes exist about some of the questions listed below. This information will only be used by our team to helps us prepare for the best experience possible for you.

Please indicate if you have had any of the following

I have experienced an emotional or mental health crisis in the past yearI have experienced DepressionI have experienced AnxietyI have experienced Panic AttacksI have experienced Psychological DistressI have experienced Bipolar DepressionI use non-prescription drugs or alcohol regularlyI have experienced any other mental health issueNone of the above

Please share anything you've experienced with Depression, Anxiety, Psychological Distress, Panic Attacks, Bipolar Depression or any other mental illness. ALSO, please indicate when this started and how it may impact your participation at the Program.

Please tell us about your non-prescription or alcohol use (how much and how often)

Please tell us the nature of the emotional or mental health crisis you had in the past year and how it was resolved

Have you been hospitalized for a mental health related issue or psychiatric illness in the past year?

Have you experienced suicidal thoughts in the past year?

HEMATOLOGY/ONCOLOGY

Are you taking any blood thinners such as warfarin (Coumadin), low-molecular weight heparin injections (Lovenox), or any other blood thinner medications (do not include aspirin)?

Please explain type, dose, and frequency

Do you have Immunosuppression (low immune function?)

Do you have a history of or currently have cancer?

Oncology Questions

Diagnosis

Date Diagnosed

Are you currently receiving cancer related medical care?

Please Explain

Did you receive chemotherapy?

Date of most recent chemotherapy?

Have you received radiation therapy?

What area of the body was radiated?

Date of last radiation therapy

Are you in remission or no evidence of disease?

When were you listed as being in remission or no evidence of disease? (Approx Date)

Have you had any relapse?

When did the relapse occur?

If you have ever had a tumor or tumors, please list location(s)

Oncologist, Radiologist, Specialist, Or Family Physician Info

(Whoever you see the most frequently)

Name

Hospital/Institution

Street Address

City

State/Province/Region

Postal/Zip Code

Office Phone

Emergency Phone

Additional Team Info

Do you see a Social Worker?

Social Worker Name

Social Worker Phone

Social Worker Email

IMMUNOLOGY AND INFECTIOUS DISEASE

Please indicate if you have had any of the following

A history of Chicken Pox or the Chicken Pox vaccineThe annual Influenza vaccine (Note: The Influenza vaccine is strongly encouraged but not required to attend a FD program)The COVID-19 vaccine (Note: The COVID-19 vaccine is strongly encouraged but not required to attend a FD program. Only answer yes if immunization shots have been/will be completed by the time of the Program.)None of the above

What type of COVID-19 vaccine (e.g. Moderna, Pfizer, Other)?

Have you completed the series of shots (e.g. both shots for Moderna and Pfizer)?

What dates did you receive the first shot?

What date did you receive the second shot if applicable?

Do you have a history of splenectomy or splenomegaly?

Do you have a chronic autoimmune condition (e.g. Lupus, Rheumatoid Arthritis, etc.)

Please Explain

EYE AND EAR

Do you have any significant vision or hearing limitations?

Please explain hearing/vision impairment

ORTHOPEDIC AND MUSCULOSKELETAL

Do you have a history of limb amputation, significant weakness of an extremity or have trouble walking unassisted?

Please describe any amputation, physical disabilities, and/or limitations:

FUNCTIONAL/ENVIRONMENTAL

Please indicate any physical actions or activities that you would not be able to do at the Program (check all that apply)

I wouldn't be able to climb a ladder or steep stairsI cannot dunk my head under water and holding my breathI wouldn't be able to lift more than 25 poundsI cannot spend time at Altitude (above 6000 feet)I cannot swimI cannot walk a mile or for 30 minutes consecutivelyNo concerns with anything listed above

Please explain why you may not be able to perform any of the above actions or activities

Are you able to sit upright with your legs in front of you for 4+ hours at a time?

Do you experience any problems with heat or cold weather temperatures?

Please explain any problems you have with hot or cold temperatures including how you typically manage this.

Do you have any spasticity, numbness, pain, tingling, or burning in your extremities?

Please explain any spasticity, numbness pain, tingling, or burning in your extremities.

Are you able to maintain a firm grip?

Are you able to independently move from a seated position to a standing position?

Please describe any fatigue you might have. Please also note if it is all of the time or only after certain activities

SURGICAL

Please list past surgical history:

MEDICATION

Please list ALL current medication and dosage schedule:

ALLERGIES

Please indicate if you have any of the following physical conditions that may affect your participation in the Program (Check all that apply. Please review our adaptability guidelines for more information on how we use this information)

Severe food allergySevere allergies to medicine, environment, or otherNone of these apply to me

Please List ALL severe allergies (food, environment, etc) the type of reaction you have (anaphylaxis, hives, etc) and if you carry an epi pen

Please List any food or diet preferences you have. (Vegetarian, Kosher, Gluten Free, etc)

Healthcare Worker Questions

Name of Employer

What type of healthcare worker are you?

If other healthcare role, please explain

Type of medical of healthcare facility you work in

What are your basic day to day responsibilities?

Please provide your professional healthcare license or registration number

Have you provided direct care to suspected or Confirmed COVID-19 patients?

How often have do you provide direct care to suspected or confirmed COVID-19 patients?

Volunteer

Are you an FD Alumni?

What type of alumni?

Do you have a valid drivers license?

Are you comfortable driving a larger vehicle with 5-7 passengers at a program?

Please explain why you are not comfortable with driving

The following conditions are considered higher risk for COVID-19, according to the Centers for Disease Control and Prevention, or they are conditions of interest to FD. Please note that COVID-19 is a new disease and there is limited data and information about the impact of underlying medical conditions. CDC may make updates to this list periodically. If you notice a certain condition that is important for FD to be aware of that is not listed, please be sure to include it in the “Other” section below. Please indicate if you have a history of or is currently experiencing any of the following and provide details, as necessary (check all boxes that apply):

CancerChronic Kidney DiseaseCOPD (Chronic Obstructive Pulmonary Disease), cystic fibrosis, pulmonary fibrosis, and other chronic lung diseases. Current smokerDiabetes (Type 1 or 2)Down SyndromeHypertension or High Blood PressureImmunocompromised state (weakened immune system)-solid organ transplant, blood, or bone marrow transplant; immune deficiencies; HIV with a low CD4 cell count or not on HIV treatment; prolonged use of corticosteroids; or use of other immune weakening medicinesLiver DiseaseModerate to Severe AsthmaMultiple SclerosisNeurological Conditions (e.g. dementia)Obesity (Body Mass Index of 30 or above)Currently Pregnant (or may be pregnant)Serious Heart Condition or Disease (such as heart failure, coronary artery disease, or cardiomyopathies) or other Cardiovascular and cerebrovascular diseasesNone

Do you have any other medical conditions or activity restrictions not covered above that may impact your participation?

YesNo

Please explain additional medical conditions or activity restrictions that you have

First Descents wants to recognize that every BODY is different and we will do our best to work with outfitters to accommodate our participants; however there are some restrictions with the equipment for activities such as kayaking and climbing. If you have concerns about how the equipment may or may not fit with your body (prosthetics, BMI, medical equipment, etc), please indicate that here so a staff member can speak with you directly about what options are available.

Can you describe any concerns or apprehensions you have about the program (if any)?

Do you have any goals you're looking to achieve in your First Descents Adventure (if yes, please explain)?

Photo Release

I hereby give First Descents permission to photograph, record audio and/or record videos of me during the Program (the "Photos"). I also authorize First Descents, at its sole discretion, to use the Photos in First Descents publications, marketing and promotional materials, including but not limited to, on First Descents website, social media accounts and fundraising materials. Initial Here

Media Involvement

A media representative may be joining us to write or film a story on your First Descents program. As part of this process, they may be interested in interviewing participants to feature in the piece. The crew will be non-intrusive, and respect the privacy of our participants as well as the integrity of our program experience. Are you interested/comfortable with being on camera and/or interviewed?

First Descents Cancellation Policy

At FD, we’ll do everything in our power to make this adventure a reality for you. However, we understand that sometimes life throws curve balls, and you might not be able to attend the program that you’ve committed to. We simply ask that you please notify us immediately if you’re unable to attend, so that we are able to give this amazing opportunity to another participant.

I have read and agree with the above Cancellation Policy

Contact Information