Colorado Trek 2015 - High Adventure Treks

Colorado Trek 2015
Information Binder
1
Contact
Information
2
Adventure Experience Camp
#2 Illinois Creek
Almont , CO 81210
(970) 641-4708
http://www.advexp.com/
MapQuest
latitude
longitude
38.765219 -106.612291
Owner's: Tim and Linda
Program Director: Lewie Foltz
Program Assistant: Stine Taylor
Noah's Ark Whitewater Rafting
23910 US HWY 285
Buena Vista, CO 81211
(719) 395-2158
http://noahsark.com/
MapQuest
latitude
longitude
38.765875 -106.096223
AEI camp does all set up and communication with Noah's Ark
Capulin Volcano National Monument
46 Volcano Road
Capulin, NM 88414
(575) 278-2201
MapQuest
latitude
longitude
36.778533 -103.979727
Great Sand Dunes National Park
Mosca, CO
(719) 378-6395
3
Best Western
Best Western Alamosa Inn
2005 Main St
Alamosa, CO 81101
(719) 589-2567
MapQuest
latitude
longitude
37.470116 -105.88279
This reservation is made for you by HATS.
Best Western Windsor Inn
1701 S Dumas Ave
Dumas, TX 79029
(806) 935-9644
MapQuest
latitude
longitude
35.846155 -101.973381
You will need to make this reservation on your own. Let them know you are with HATS and you
should get a special rate.
Best Western Plus- Raton Hotel
473 Clayton Rd
Raton, NM 87740
(575) 445-8501 ext. 132
www.bwratonhotel.com
MapQuest
latitude
longitude
36.884945 -104.434744
You will need to make this reservation on your own.
4
Lunch and Dinner
287 Road House - Friday Dinner in Dumas
1621 S Dumas Ave
Dumas, TX 79029
(806) 935-0287
http://www.287roadhouse.net/
Located next door to Best Western Windsor Inn
Sand's Restaurant - Saturday Lunch in Raton
350 Clayton Rd
Raton, NM 87740
Main Number: (575) 445-4024
MapQuest
latitude
longitude
36.884949 -104.436922
Manager: Maurice
Cell: (575) 303-3063
Mexican Food Buffet - Served at 12:30PM - Should be $9 per person (If it is a small group you
will order off the menu)
 Chicken & beef fajitas - with flower and corn tortillas
 Beans
 Rice
 Beef Stew
 Salad Bar
5
San Louis Valley Pizza - Saturday Dinner in Alamosa
2069 First St
Alamosa, CO 81101
Main Number: (719) 589-4749
MapQuest
latitude
longitude
37.472912 -105.887161
Owner: Randall
Cell: (719) 298-0223
Son: Alex
Pizza - Delivered to Best Western at 9:45PM - Should be $7.65 per person including gratuity
 14 Pizzas (for 55 people) assorted toppings
 6 or 7 Pizzas (for 20 people)
 Salad
 Tea and Lemonade
K's Old Fashioned Burgers - Sunday Lunch in Buena Vista
223 Highway 24
Buena Vista, CO 81211
(719) 395-8695
MapQuest
latitude
longitude
38.853205
-106.167062
You are not required to eat here, but it is highly recommended. They get food out quickly and
there is a nice park behind the restaurant to eat lunch and relax AND IT IS DELICIOUS!! Try to
eat before noon.
6
Schedule
&
Itinerary
7
Colorado Trek - Itinerary
Friday – Leave for Colorado (if this fits in your schedule) Arrive in Dumas - check into Best
Western then eat dinner.
Saturday – Leave Dumas (8:00am) to climb Mt. Capulin volcano (this is optional) then head to
Alamosa. Lunch at Sand's Restaurant 12:30PM
Saturday – Arrive in Alamosa, check into hotel by 4:45PM then to Great Sand Dunes. Dinner at
9:45PM at Best Western.
Sunday – Drive to AEI camp. Lunch in Buena Vista then hike at continental divide. Arrive at AEI
by 3:30PM.
Monday – Adventure Race and High ropes course day
Tuesday – Rock Climbing and ATV day - Dad and Sons ride together in caravan up private
mountain road to experience wonderful views at 13,000 feet
Wednesday – Backpacking (3 days)
Thursday – Peak Assent
Friday – Return to AE camp from backpacking- sauna, and showers!
Saturday – White Water Rafting day (ends about 4) & begin drive back to Dallas
Sunday – Drive back to Dallas
8
CAMP DIRECTOR AGENDA AND NOTES
COLORADO TREK 2015
FRIDAY: Suggest to group to travel as far as possible on Friday, arriving in Dumas would be ideal. If you
do stay in Dumas, most HATS teams stay at the Best Western. A great place for dinner is
287 RoadHouse, located next door to the Best Western, they can accommodate a large
group and the food is good, if you want to eat with the group meet there at 7:00PM!
Let everyone know to gas up and make any last minute purchases at the Walmart on
Friday night; we will be leaving early Saturday morning.
A number of teams made it to Amarillo or further and arrived in Alamosa on Saturday
more refreshed than the Dallas group leaving Saturday at 5:00 AM. This group did arrive
in Alamosa by 4:00 PM and had time to check in get into their rooms and were ready for
the Great Sand Dunes by 4:45.
EVERYONE PUT A HATS STICKER ON YOUR CAR, THIS REALLY HELPS WITH CARAVANING!
SATURDAY:

6:00 - 7:30 AM. Breakfast.

8:00 AM. Meet in parking lot, cars should already be packed and ready to go.

Take roll call and a count of how many vehicles there are

Discuss logistics about Mt. Capulin – There are a limited number of
parking spots so get in as few cars as possible, there is a $5 fee per car.
The sooner you get there the better! There is also a parking lot at the
bottom of the mountain where you can leave extra cars. The office is also
located here; you will need to go inside to make payments. Don’t forget
to take a group picture at the top.

Load cars - lose convoy is fine - leave by 8:10

12:30PM. Lunch at Sand's Restaurant in Raton

1:30 PM. Leave lunch and head to Best Western in Alamosa

3:30 PM. Camp director should arrive in Alamosa to check into room, work with
hotel staff, set up meeting area and oversee welcoming reception in the lobby. Also
call Randall at San Louis Valley Pizza to order pizza and setup delivery to hotel.

5:45 PM. Head back to rooms to gather up day packs, rain gear, flash lights, water,
snacks. Highly recommend long pants and shirts, hats, bandanas, flash light and sun
glasses or SKI GOGGLES! It will get very cool at sun set and if the wind is blowing at
all, it is like a sand blast on arms and legs. We wore tennis shoes (or light hiking
boots) with gaters to keep sand out of shoes and socks. Some of the boys hiked
bare footed on the dunes which worked ok until it got cold
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
6:30 PM. Arrive at Great Sandunes Nat’l Park at the main parking lot (2nd parking
lot). Car convoying is not necessary and the travel arrangements and arrival times
varied for the group (late arrivals at hotel needed more time to unpack and repack
for the Dune evening). Take group pictures and head for the dunes. At the
entrance/exit hang some glow sticks on the trees in a bundle so you can see the exit
when it’s dark.

Walk the ridge lines to the top and drop over the edge about 30 feet to get out of
the wind and for best viewing of the sunset. Encourage all to go to the peak as it is a
memorable experience! MAKE SURE YOU FILL UP GAS TANKS ON THE WAY BACK TO
THE BEST WESTERN. THIS WILL SAVE A GREAT DEAL OF TIME ON SUNDAY!!

9:45PM. Arrive back at hotel, chow down on pizza in lobby, clean out sand, go to
bed!

6:30 AM – 8:15 AM. Continental Breakfast at the hotel is very good and plenty of
food. Pack up cars. Camp director give check for hotel bill.

8:30 AM. Group meeting.
SUNDAY:

Play the Name game: Have each Son say what he would like to be when
he grows up and then have dad say what he wanted to be (at age 15)
when he grew up and have him say what he does now.

Talk about the schedule for the day. Explain that if each person is late 5
to 10 minutes for each meeting during the week, we as a group will lose
½ day of our week! To illustrate, hold up a dollar in one hand and a dime
in the other hand. The saying is “A dollar waiting on a dime”! Ask group
which has the most value, a dollar or a dime? How many pennies make
up a dollar? How many pennies make up a dime! Is it fair for 100 to be
waiting on 10? Remember this saying this week and don’t you keep a
dollar waiting on a dime!

Go over map and directions at group meeting. Basically very one needs
to meet in Buna Vista around 11:00 AM.

9:00 AM. Head out in a loose convoy for Buena Vista.

11:00 AM. Main street holds a number of small restaurants. The church crowd hits
at noon so be eating before then. K's Old Fashioned Burgers is where EVERYONE
should eat. It is super fast, yummy and has a great park behind the restaurant where
you can eat. Kipp and I tried to eat somewhere else last
year and ended up going back to K's because it was so fast,
AND YUMMY!!

12:00 PM. The road to Cotton Wood Pass is at the main
light on Main Street. THE ONLY LIGHT. Hwy 306. It is about
a 30 minute drive to the top of the pass. There is a large
10
parking area at the summit. The Cotton Wood Pass elevation sign is a good
gathering spot for group picture and is the trail head to hike up toward the peak.
Also take dad and Son pictures with the lake in the background

1:00 PM. Pictures and then do a 30 minute hike up the pass trail and 30 minutes
back. Day packs, water and RAIN GEAR. Our group hiked in sleet a few years ago, to
make sure everyone was set up with the right gear for the coming week. Good
advice and a good hike! REMEMBER: We don’t cancel for inclement weather!!

2:00 PM. Load up and head to AE camp. Be careful driving down the pass, this is a
popular RV and ATV area and this is the shortest way back to Denver for the
weekend warriors… lots of traffic. At dead end (Road #) stop and make sure
everyone is now in a tight convoy. AE entrance is hard to find. See photo of house
on the left side of the road with wraparound porch. There is a pink flamingo on mail
boxes on the right side on the road, turn right after this line of mail boxes.

3:30 PM. Arrive AE Camp. Pull up to office parking lot and have everyone gather at
fire ring assembly area.

Assign cabins - if a large group have everyone draw out of a hat

Assign groups - if there are more than 10 teams

DAD AND SONS SIT TOGETHER AT MEALS!

Brief Guides Sunday: We have all been together 5 years / 75 mirror
questions / 30 team building games/ please keep everything positive,
upbeat with bonding in mind NOT the activities.

HATS goal for this week is to strengthen the bonds, not the bodies!

4:00 PM. Admin meet to go over paperwork while teams moves into cabins.

5:50 PM. Meet for dinner at double doors of dining hall.

6:00 PM. Dinner DAD AND SON ALWAYS SIT TOGETHER - DON'T BE SCARED TO CALL
SOMEONE OUT!!!

7:30 PM. Beattitudes in Chapel

8:30 PM Circle up & group name game
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



Break into backpacking groups (if there are more than 10 teams, if there
are less than 10 teams do all this as 1 group) - Hand out bandanna's HATS
group only (guides receive theirs at the end of the week)

Come up with group name

# system for counting off

Nametag boys (2) there are 2 rolls of glow-in-the-dark duct
tape.
Small group name game

What will the Son’s main activity be his sophomore year?

What was dad’s main activity his sophomore year?

What high school they went to/go to?
If time - # game 1-10 : go in random orders around the circle and see if
you can count to 10. If two people say the same number at the same
time you start over! You cannot go in a specific order
9:00 PM Dad & Son breakout questions in chapel

What do you want to get out of this week?

What are you scared of?

What are you really excited about doing?

How do we make sure we have our own time together aside from the
group?

What can we do to take our own time together when we get back home?

9:20 PM Go to cabin & get ready for bed


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8:00 AM Breakfast (8:15ish)
9:30 AM Meet to begin games
10:00 AM Staff Game – Colorado Trek Baseball?
10:15 AM Potty break, picture of group
10:20 AM Head to Adventure Race
12:30 PM Lunch – Dad & Son photos
1:45 PM High Ropes
6:00 PM Dinner
Monday Night Break out Questions
 What was the hardest part for us to do
together on the pamper pole?
 How did you control your fears during
the high ropes course?
MONDAY:
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


How did I help you/support you throughout the ropes course day?
What will we remember most about this day in 5
years?
After Breakout – duck tape poopie bags for backpacking –
different colors of duck tape
TUESDAY:

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7:45 AM Breakfast: ATV group eats first
8:45 AM Leave for ATV / Rock Climbing
9:00 AM Arrive @ ATV Rental
 Dad and Sons ride together in caravan up private
mountain road to experience wonderful views at 13,000 feet
 Sign paperwork
 Get helmets
 Practice driving
 HATS will cover any damages – Please make sure to look over your ATV
very well, inside and outside of tires, undercarriage, ext…
 AEI will have copies of your driver's license
 Must be 18 with drivers license to drive
10:00 AM Leave to go ATVing
1:00 PM Rock Climbers & ATV arrive at Trading Post – switch, eat lunch in cars (if
there are two groups)
4:30 PM Back to AE Camp – Rock Climbers start showers
5:30 PM Vans go back to pick up ATVers (if two groups) ATVers will probably
shower after dinner or after gathering backpack supplies
6:00 PM Dinner
7:30 PM Gather gear for Backpacking and spend the rest of the night packing your
backpack and taking showers
8:00 PM Dad's if you need to get backpacking gear from your car let an AEI guide
know and they will bus you to the cars and bus you back.
WEDNESDAY - FRIDAY
 Backpacking!!!!! Don’t forget pictures!

Return Friday for showers and sauna
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
5:00-6:00 PM Dad's pickup cars while boys are in the chapel signing bandannas for
the AE guides that helped with your group - all boys sign every bandanna - also do
one for Kipp and Megan - Megan likes to put them on the walls in her office :)



6:00 PM. Dinner - Present tip and bandannas to your guides
7:00 PM. Chapel to hear owner Tim tell story
7:30-8:30 PM. Yarn Toss in groups - everyone picks a person to toss the yarn to and
tell them about something they did this past week that inspired you/ made you
proud of them ext.
8:30 - 9:00 PM. Everyone circle up and say your Thanks for the week - what were
you thankful for this week.
9:00 - 10:00 PM. Pack your cars and leave at the cabins


SATURDAY:




6:30 AM grab breakfast on your way to WHITEWATER RAFT!!!
We recommend paddle boats. The only boats to ever flip in the past were the oar
boats and when you get to paddle it's so much more fun!
Noah’s Ark might say the boys are too young to paddle in the oar rafts. Please let
them know the boys have been whitewater kayaking and are very fit to whitewater
raft. I have talked to them so there should be no problems.
Raft all day finishing around 4:00PM
Most will drive back to Raton and stay at the Best Western.

Finish driving Home!!

SUNDAY:
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Gear Lists
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Colorado Backpacking Trip Equipment List
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46.
Duffle bag
Backpacking sleeping bag (down to zero degrees).
Sleeping pad
Sleeping bag liner
Camping pillow
Backpack
Backpacking tent
Day Pack
First Aid kit
Toiletries
Camera
Knife
Insect repellent (one medium-size can or bottle per camper)
Sun Screen (both cream and spray)
Chap Stick
At least 4 Carabiners of various sizes (to clip shoes, water bottles, etc to packs)
Snacks (Power Bars/nuts/fruit snacks/trail mix, etc.)
Bath towel and wash cloth
Moist towelettes and/or diaper wipes
Backpacking toilet paper
Chap stick
Headlamp and small flashlight
Two 32-ounce water bottles (Nalgene)
Two pairs of convertible pants (Columbia, North Face)
Two pairs of wicking material underwear (Under Armour or other brand)
Two wicking material short sleeve T-shirts (Under Armour or other brand)
Two wicking material long sleeve T-shirts (Under Armour or other brand)
One long sleeved over shirt
Fleece jacket and/or vest
Long underwear
Pair of gloves (Plainsman or other brand)
Rain gear (with hooded jacket)
Mess kit
3-5 HATS T-shirts
Hiking boots
Camp shoes (water shoes, enclosed-back sports sandals, or athletic shoes) Note: Flip flops and
Crocs are not permitted on White Water rafts
3-4 pairs of wool socks
2-3 pairs of cotton socks
2-3 extra pairs of regular underwear
Cap with sun visor
Wool cap that goes over ears (HATS cap)
At least two extra changes of clothes (for drive in and drive out)
Enclosed wrap around sunglasses or sun goggles (to keep out dust while riding ATVs and hiking
in the wind)
Crazy Creek or other brand of outdoor camping chair
Bungee cords and/or rope (for tying food in trees to prevent access by chipmunks)
At least one large garbage bag and one tall kitchen garbage bag with draw strings (to protect
sleeping bag and clothes in backpack)
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47. Used gallon and quart size zip lock bags (to protect various items and to carry out refuse from
camp sites)
48. 2-3 extra bandanas
Optional but Highly Recommended
1.
2.
3.
4.
5.
6.
7.
8.
9.
Trekking Poles
Ear Plugs (to protect against snoring disruptions)
Gaiters (to protect legs when hiking)
Anti-itch cream
Water bladder (at least 3 liters)
Reading material
Note book and pen/pencil
Watch with alarm
Pain Reliever (aspirin, etc.)
Optional
1.
2.
3.
4.
Water filter
Water purification tablets
Back Packing stove
Instant Coffee
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Maps
&
Directions
20
Directions and Map
Capuulin Volcano
Interstate 25 is the major north/south
route through the state. The monument is
located 33 miles east of Interstate 25 at
Raton, NM, via US Highway 64/87. The
park entrance is on New Mexico Highway
325, 3 miles north of the town of Capulin
which is at the junction of NM Hwy 325
and US Hwy 64/87.
From the east, the monument is 58 miles
west of Clayton, NM, also via US
Hwy64/87.
Great Sand Dunes National Park
To access the main park area,
including the Dunes Parking Lot,
Visitor Center, and Pinyon Flats
Campground, take Highway 150
from the south or County Road 6
from the west. Both are paved
highways.
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Tips
&
Tricks
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25
Colorado Advice From Tom Harrison
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Drink water until you think you will get sick….and then drink some more.
Don’t give up regardless of how tired you get.
Rely on your Son.
Make sure there is a John Parrish in the group so they can carry a second backpack when a
camper is exhausted and thinks they can’t finish.
Take tons of pictures regardless of how much the boys protest.
Buy the best raingear you can get and pray you don’t need it.
Even though you are tired on the trail up the mountain, make sure you take the time to pick a
good ten location and to protect yourselves from rain.
Altitude will change lots of things. Be prepared for somewhat “foggy” thinking.
Do not change course up the mountain. Complete the original plan.
Take a few granola bars for energy.
Take layered clothing, sunglasses, sunscreen, gloves.
Don’t be cheap. Buy GOOD hiking boots. The great deal you got will be forgotten when your feet
or your Son’s feet are hurting.
Break the boots in BEFORE you go to CO. Wear them to work. Good advertising for HATS!
Be prepared to laugh, love and maybe even cry a little at the beauty of the surroundings and
having your Son all to yourself.
Get wet on the white water rafting and splash the other boats with a vengeance.
Be a kid again.
Disney calls their parks the “Magic Kingdom”…..they can’t hold a candle to spending time with a
precious Son. Being with them creates a truly “Magic Kingdom”.
We will be with them in spirit.
Tom
26
Paperwork
&
Check List
27
Colorado Trek Paper Work
Check List
 HATS Release Form
 Adventure Experience Release Form
 Dad
 Son
 AE Camp Registration Form
 Health Statement Form (signed by doctor)
 Dad
 Son
 Health History Form
 Dad
 Son
 Immunization Forms
 Son
 Noah's Ark forms
 Dad
 Son
 Copy of Dad's Drivers License for ATV day
28
29
Son's Form
30
Dad's Form
31
PLEASE COMPLETE - DAD
Group Name:
Participant:
Address:
City:
Home Phone:
Trip Date:
Date of Birth:
Gender:
Zip:
Fax/Email:
PLEASE COMPLETE - SON
Group Name:
Participant:
Address:
City:
Home Phone:
Trip Date:
Date of Birth:
Gender:
Zip:
Fax/Email:
In Case of Emergency Notify:
Parent/Guardian/Spouse:
Home Phone:
Home Address:
Work Address:
If not available, notify:
Home Phone:
Home Address:
Health Care Information:
Name of Physician:
Address:
Date of last physical exam:
Do you carry family medical/hospital insurance?
Carrier:
Do you have any special food needs? (ie: vegetarian)
Please describe:
Ht.
Wt.
Ht.
Wt.
Work Phone:
Relationship:
Work Phone:
Phone:
YES
32
(within the last 24 months for those under 18)
NO
Policy or Group #
Health Statement by Licensed Medical Personnel
Dad's From
Participant's Name:
Birth Date:
Trip Date:
This program proposed for the above named participant requires participation in activities which are
physically challenging, at "high altitude" (9,000 to 13,000+ feet) and in a remote, wilderness environment.
These factors can cause surges in blood pressure and heart rates as well as other conditions. Therefore, all
participants must be free of medical or physical conditions which might create undue risks to themselves or
others. Your response to these questions will aid in the medical screening and care of the participant.
I have examined the above participant within 24 months of program date. Date of examination:
In my opinion, the above participant
IS
IS NOT
able to participate in the described program.
Description of any limitations or restrictions on program activities:
The participant is under the care of a physician for the following conditions:
Current treatment at the time of this report includes:
Prescribes medications being used by participant:
Over-the-counter medications used by participant:
Any dietary restrictions:
Known allergies or drug reactions:
Signature of Physician or Nurse Practitioner:
Printed Name:
Title:
Address:
Phone:
Date:
33
Health Statement by Licensed Medical Personnel
Son's From
Participant's Name:
Birth Date:
Trip Date:
This program proposed for the above named participant requires participation in activities which are
physically challenging, at "high altitude" (9,000 to 13,000+ feet) and in a remote, wilderness environment.
These factors can cause surges in blood pressure and heart rates as well as other conditions. Therefore, all
participants must be free of medical or physical conditions which might create undue risks to themselves or
others. Your response to these questions will aid in the medical screening and care of the participant.
I have examined the above participant within 24 months of program date. Date of examination:
In my opinion, the above participant
IS
IS NOT
able to participate in the described program.
Description of any limitations or restrictions on program activities:
The participant is under the care of a physician for the following conditions:
Current treatment at the time of this report includes:
Prescribes medications being used by participant:
Over-the-counter medications used by participant:
Any dietary restrictions:
Known allergies or drug reactions:
Signature of Physician or Nurse Practitioner:
Printed Name:
Title:
Address:
Phone:
Date:
34
AEI Base Camp Health History Form
Dad's Form
(Please Print Neatly)
The purposed program provided by Adventure Experience, Inc. requires participation in physical activities which are, by nature, physically demanding.
many of the activities as well as being high altitude will challenge you, both of which can cause surges in blood pressure and heart rates. it is imperative
that you are free of any heart related or other diseases. therefore, all participants must be free of medical or physical conditions which might cause undue
risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of outdoor activities. As required by the
State of Colorado, participants under the age of 18 must submit a statement confirming a physical examination within the last 24 months by a physician
or nurse practitioner.
Name:
Birth Date:
Age:
Health History: (Circle the appropriate response and describe any yes answers.)
Have you had or do you currently have any heart problems, i.e, strokes, heart attacks, and/or heart related diseases?
YES
NO
Do you frequently suffer from pains/pressures in your chest?
YES
NO
Do you often feel faint of have spells of sever dizziness?
YES
NO
Has a doctor ever told you that you have high blood pressure?
YES
NO
Are you a smoker?
YES
NO
Do you have arthritis, joint or back problems that might be aggravated by exercise?
YES
NO
Have you had any operations, serious injuries or illnesses? (dates)
YES
NO
Do you have any disabilities or communicable diseases?
YES
NO
Are you allergic to any medications, insects or pollen?
YES
NO
Are you allergic to any foods?
YES
NO
Do you have Asthma?
YES
NO
Do you have Epilepsy?
YES
NO
Do you have Diabetes?
YES
NO
Do you have any prescribed meal plan or restrictions?
YES
NO
Are you currently sick and/or using a medication not listed above?
YES
NO
(NOTE: If you have had any heart related problems you will need to have a release from a physician in order to participate in any camp activities.)
List any activities to be limited or prohibited:
Suggestions or health related information for A.E. Personnel:
General Health Statement:
REPRESENTATION AND EMEMRGENCY AUTHORIZATION
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as
noted. I hereby give permission to the medical personnel selected by Adventure Experiences, Inc. or its agents to order x-rays, routine tests and
treatments as well as injections and/or surgery for me or my child as named above. Such authorization for emergency treatment shall also include, but
no be limited to, changes incurred for the providing of aid and arranging evacuation if Adventure Experience, Inc. or its agents, determine that such
evacuation in necessary or desirable. i further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical
care and acknowledge that these costs are the financial responsibility of the undersigned. I also understand and agree to abide with the restrictions
placed on my camp activities.
Signature of Participant:
Date:
Signature of Parent/Guardian (if under 18):
Date:
Witness:
Date:
35
AEI Base Camp Health History Form
Son's Form
(Please Print Neatly)
The purposed program provided by Adventure Experience, Inc. requires participation in physical activities which are, by nature, physically demanding.
many of the activities as well as being high altitude will challenge you, both of which can cause surges in blood pressure and heart rates. it is imperative
that you are free of any heart related or other diseases. therefore, all participants must be free of medical or physical conditions which might cause undue
risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of outdoor activities. As required by the
State of Colorado, participants under the age of 18 must submit a statement confirming a physical examination within the last 24 months by a physician
or nurse practitioner.
Name:
Birth Date:
Age:
Health History: (Circle the appropriate response and describe any yes answers.)
Have you had or do you currently have any heart problems, i.e, strokes, heart attacks, and/or heart related diseases?
YES
NO
Do you frequently suffer from pains/pressures in your chest?
YES
NO
Do you often feel faint of have spells of sever dizziness?
YES
NO
Has a doctor ever told you that you have high blood pressure?
YES
NO
Are you a smoker?
YES
NO
Do you have arthritis, joint or back problems that might be aggravated by exercise?
YES
NO
Have you had any operations, serious injuries or illnesses? (dates)
YES
NO
Do you have any disabilities or communicable diseases?
YES
NO
Are you allergic to any medications, insects or pollen?
YES
NO
Are you allergic to any foods?
YES
NO
Do you have Asthma?
YES
NO
Do you have Epilepsy?
YES
NO
Do you have Diabetes?
YES
NO
Do you have any prescribed meal plan or restrictions?
YES
NO
Are you currently sick and/or using a medication not listed above?
YES
NO
(NOTE: If you have had any heart related problems you will need to have a release from a physician in order to participate in any camp activities.)
List any activities to be limited or prohibited:
Suggestions or health related information for A.E. Personnel:
General Health Statement:
REPRESENTATION AND EMEMRGENCY AUTHORIZATION
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as
noted. I hereby give permission to the medical personnel selected by Adventure Experiences, Inc. or its agents to order x-rays, routine tests and
treatments as well as injections and/or surgery for me or my child as named above. Such authorization for emergency treatment shall also include, but
no be limited to, changes incurred for the providing of aid and arranging evacuation if Adventure Experience, Inc. or its agents, determine that such
evacuation in necessary or desirable. i further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical
care and acknowledge that these costs are the financial responsibility of the undersigned. I also understand and agree to abide with the restrictions
placed on my camp activities.
Signature of Participant:
Date:
Signature of Parent/Guardian (if under 18):
Date:
Witness:
Date:
36
Dad's
37
38
39
Son's
40
41
42