2022 Ouray Ice Climbing February 6-11

Oncology 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 select the response that best applies to your program registration (note: if you fall under multiple categories, please choose the best option that fits the program you'd like to attend)

Which program are you interested in attending?

Are you currently between the ages of 18-45?


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

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

Have you attended an overnight program with FD in the past?

Oncology and MS Eligibility

What age were you diagnosed with MS or Cancer?


**PLEASE NOTE you must be have been diagnosed between the ages of 15-45 to be eligible for this program **

Oncology/MS Caregiver Questions

Are you the primary caregiver for an individual who qualifies for one of our MS or Oncology Programs? (they were diagnosed and treated for either MS or cancer between the ages of 18-45)

YesNo


**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**

Are you a caregiver for an individual living with MS or living with cancer?

Let us know the full name of the individual you are a caregiver for

Are you the only Caregiver applying for an FD program for the person listed above?


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

What is your relationship to the individual you are a caregiver for?

If you selected other, please specify your relationship

Healthcare Worker Information

What type of healthcare worker are you?

Name of Employer

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 if applicable.

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?

Personal and Contact Information

Email Address

Confirm Email Address

First Name

Last Name

Street Address

Address Line 2

City

State/Province/Region

Postal/Zip Code

Home Phone

Mobile Phone

How did you hear about us?

Which Physician, Nurse, or Social Worker did you hear about us from?

Which patient advocacy group or organization did you hear about us from?

Which patient hospital or clinic did you hear about us from?

Let us know the other way you heard about us

How do you identify your gender?

Edit this text

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

T-shirt size

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.

Would you like to apply for a Travel Scholarship?

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.

What is your employment status?

Please select what best applies to you.

Do you have any dependants?

What form of transportation will you be using to get to and from your program? FD Scholarships cover the primary mode of transportation only.

*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.

Approximately, how much will your primary from of transportation cost to get to and from your program?

How much are you requesting FD to help you cover? *FD encourages Scholarship applicants to contribute whatever amount they can afford and ask for financial support for the remaining amount.

Do you have the means to initially cover the cost of your travel (e.g. credit card, cash, etc.)? As a reminder, FD Scholarships are reimbursement based meaning you cover the initial cost and then FD reimburses you after you complete your program.

Explanation of Financial Need: We want to fully understand your financial situation in as much detail as possible. Please explain your need for financial support. (250 characters or less)

Personal Motivation & Commitment: Tell us about your story. Why do you want to go on a FD program? What are you hoping to learn and gain? What makes you a great candidate for a scholarship? Please provide any additional information if you feel that the financial information you provided does not accurately reflect your needs. (250 characters or less)

Please initial the following:

I acknowledge and understand the FD Scholarship process

The information provided by me is true and complete to the best of my knowledge. I understand that withholding or misrepresenting my financial need and situation could affect others and my participation.

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

Are you interested in participating in the NIH study?

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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.

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

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

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.

Signature

Date of Signature

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:

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.
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.

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

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

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Pre Program Health Agreement

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.