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2022 Ouray Ice Climbing January 30 - February 4

Healthcare Worker Registration Form


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.


During a First Descents Program, participants will have the opportunity to partake in various activities. These activities can be strenuous and the majority of it will take place  in an outdoor environment 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. Accurate answers to the questions often allow our team to make program adjustments and help program staff members create a safer experience. 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.

FD Medical Advisory Board Statement

All FD program Participants must be fully vaccinated for COVID-19 to participate in a program. FD accepts medical exemptions, with written proof from a Physician, for Participants who are not medically eligible for the vaccination. These individuals must also provide proof of an approved negative Polymerase Chain Reaction (PCR) test 72 hours prior to the program start time. Participants may be requested to wear masks if and when necessary.

 

FD provides programs for immunocompromised individuals, and those caring for health compromised individuals. FD programs are highly interactive, including shared rooms and meal times. FD must take the appropriate measures to protect everyone against severe disease and death related to the COVID-19 virus currently circulating in the United States. Infections happen in only a small proportion of people who are fully vaccinated.



First Descents Policies 

First Descents' mission is focused on providing programs for the young adult demographic (age 18-45) across all of our communities. Eligible participants must be within this age range at the time of the program and may only attend one free program with us. We currently host programs for:   
  • Individuals impacted by MS 
  • Individuals impacted by Cancer 
  • Caregivers of an 18-45 year old individual impacted by Cancer or MS  
  • Healthcare Workers 

General Eligibility



****PLEASE NOTE that you must be between the ages of 18-45 in order to be eligible for this program****


Oncology and MS Eligibility

****PLEASE NOTE you must be have been diagnosed between the ages of 15-45 to be eligible for this program ****
Oncology/MS Caregiver Questions
****PLEASE NOTE you must be a caregiver for an individual who would qualify for one of our MS or Oncology Programs. They must be diagnosed and treated for either MS or Cancer between the ages 18-45****



****PLEASE NOTE Individuals may only have one caregiver apply for our programs****

Healthcare Worker Information
Personal and Contact Information 
Travel Scholarship Application


First Descents (FD) believes that everyone should experience the healing power of outdoor adventure.  Therefore, all FD programs are free of cost, including lodging, meals, gear and instruction. You are only responsible for covering the cost of transportation to and from the program, which typically requires fuel for a personal vehicle, an airline ticket or public transportation.  FD recognizes that not everyone has the means to cover this expense and therefore offers a limited number of Travel Scholarships to those that demonstrate financial need and personal motivation. Please keep in mind that FD is a non-profit and funds are limited. If you are unsure or don’t believe you are truly in need of a Scholarship, please give this opportunity to another applicant in need.


We recognize that access to the outdoors is a privilege and in an effort to promote access, FD encourages the most marginalized people in society to apply for a FD Scholarship, including BIPOC, LGBTQ+, women,

people from working class backgrounds, and people with disabilities. FD believes these communities must be centered in the work we do.

If you have any questions, please contact programs@firstdescents.org.

Travel Scholarship Process Overview

Travel Scholarships are to be used to support you and offset the cost of travel to and from the program only. They are also reimbursement based, meaning you will be asked to initially cover the cost and once you complete your program FD will reimburse you by check. 


Travel Scholarships can be used toward the primary mode of transportation only. Approved expenses include fuel for a personal vehicle, public transportation, airfare, and/or airline baggage costs. FD does not cover additional expenses, such as flight upgrades and/or flight add-ons, hotels, travel insurance, first class, priority seating, extra cost seat assignments, in-flight wifi or food and beverages, etc. FD also does not cover multiple expenses.


Only one scholarship can be awarded per applicant and cannot exceed five-hundred dollars ($500) without additional FD review and approval. A complete application, proof of financial need and all receipts are required to receive reimbursement. All reimbursements will be made to you directly.

*In a new tab please take a moment to research approximate travel costs for your program. If you are driving, FD encourages you to use the Fuel Economy website to determine the total cost of gas if driving. 
Please initial the following:
National Institutes of Health Study

The National Institutes of Health (NIH) in Bethesda, Maryland, is conducting a research study about the impact of some activities and practices on stress reduction. The main criteria is that your job requires/required you to directly work with patients with COVID-19 during this pandemic. Your participation will help researchers to better understand how to help healthcare workers reduce their stress in a relatively short period of time, and in a safe and effective manner. The average time commitment of the study is 45 minutes total over a 2 month period.


There is no compensation for your participation, and program participation will be free for you.  Your participation will provide valuable information to the researchers. If interested, we will provide your name, email address, and phone number to the NIH staff who will follow up with you. They will ask questions to make sure you meet study criteria.   


*Please note that agreeing to participate in this study will in no way impact your application, selection, or acceptance to a First Descents program.


If you have more questions about the study please contact the NIH at 301-827-3397 or email COVIDWellbeing@CC.NIH.GOV


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Sorry, at this time it does not look like you meet our program eligibility. If you have questions or believe you received this message by mistake, please reach out to use by text or phone (303)945-2490 or by email. 

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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.





Emergency Medical Care Authorization



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).

 


Pre Program Health Agreement


First Descents (FD) Participants, Staff, Visitors, and Volunteers must adhere to FD’s health principles and application requirements in order to attend a program. It is everyone’s personal responsibility to review and follow these guidelines.


FD’s Application & Screening Process


In light of COVID-19, FD’s program application process may include:


  1. Application: A general Participant Medical application that includes biographical and medical information, including underlying medical conditions that may pose a COVID-19 risk, as outlined by the CDC, or other medical conditions. Note: A Medical Provider Release Form is required for individuals with any underlying medical conditions.

  2. Health Screening: FD will send a general health and COVID-19 electronic screening form one to three days before the program and will conduct an in-person screening upon arrival at a program. Please report and plan to reschedule your program if you:

  • Have symptoms of COVID-19, or any other health related concerns, regardless of vaccine status. 

  • Have been in close contact (within 6 feet for at least 15 minutes) with someone who tested positive for or was suspected to have COVID-19 without use of personal protective equipment (defined as minimum surgical mask or N95, eye protection [face shield or goggles] and gloves) 

  • Live with someone who tested positive for or was suspected to have COVID-19

  • Traveled internationally, or to any restricted states, 14 days prior to the program regardless of vaccine status. You can use CDC’s Travel Planner for travel updates. It is your responsibility to know applicable travel restrictions.

  1. Vaccination record collection and/or COVID-19 testing for medically exempt Participants. Please refer to FDs’ Vaccination Policy for additional information.

  2. Please arrive at a program rested and healthy. If you’re feeling unwell in any way (e.g. common cold), please postpone your program. FD programs are highly interactive and we want everyone to show up and return home healthy. 

Program Measures


At a FD program, please be prepared to practice or employ the use of:

  • Face Coverings and Social Distancing: Face coverings and/or social distancing may be required in certain common areas (e.g. living room), and/or as instructed by FD staff. Please bring at least two (2) face masks with you. There will be some available on-site as well.

  • Hand Hygiene and Respiratory Etiquette. Please bring hand sanitizer with you. There will be some available on site as well.

  • Please do not share personal belongings, including drinks, eating utensils, hair brushes, pillows, and toothbrushes, etc.


Other 


  • Please come alone. As much as we love family, pets, and friends, please leave them at home this time (unless otherwise instructed by FDs’ Program Team). 

  • Let FD know if you require special accommodations (e.g. gear, dietary restrictions, sleeping needs, allergies, etc.) well in advance of a program.

  • Room sharing is expected on programs. Limited individual rooms may be available upon request.

  • Check the weather and pack appropriately. Bring 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 turn your cell phones off and leave them in your cars and/or rooms. FD programs are tech-free! This is a once-in-a-lifetime opportunity for you to unplug and connect in a meaningful way with yourself and others. Enjoy it!

  • Please plan to stay for the entire duration of the program and do not leave at any time unless you have been authorized to be a FD staff member. 


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. FD has put in place preventative measures to reduce the spread of COVID-19; however, FD cannot guarantee that you will not become infected with COVID-19. Further, participation in a FD program could increase your risk of contracting COVID-19.


All program participants and volunteers will be required to sign FDs’ Release of Liability and Waiver of Legal Rights ahead of each program in order to be allowed admittance. 



Emergency Contact and Medical Information

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
Emergency Contact #2
GENERAL MEDICAL 


NEUROLOGICAL
Neurologist, Specialist, or Physician Info
(Whoever you see the most frequently)
Additional Team Info
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. 
HEMATOLOGY/ONCOLOGY
Oncology Questions
Oncologist, Radiologist, Specialist, Or Family Physician Info
(Whoever you see the most frequently)
Additional Team Info
IMMUNOLOGY AND INFECTIOUS DISEASE
FD serves immunocompromised communities and requires all participants to have received the full COVID-19 vaccine in order to attend a program (unless an individual qualifies for a medical exemption). 
EYE AND EAR
ORTHOPEDIC AND MUSCULOSKELETAL
FUNCTIONAL/ENVIRONMENTAL

SURGICAL
MEDICATION
Note: You are responsible for carrying and administering your own medications during the FD program. FD encourages you to adhere to your prescription schedule. 
ALLERGIES

Volunteer

Photo Release

Media Involvement
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.

First Descents
3858 Walnut Street | Suite 161 | Denver, CO 80205
www.firstdescents.org | info@firstdescents.org
main: 303.945.2490 | fax: 866.592.6911