Email address *

Password *

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Country *

Confirm Email *

Primary Phone *

Secondary Phone

Organization or Affiliation, Church, School, Other

Where you heard from us
<---- Select One ----> Online search Friend/Word of mouth Facebook Company or Organization (specify) Other website (specify)

Specify

Gender *
<---- Select One ----> Male Female

Race (needed for grants) *
<---- Select One ----> African American American Indian Asian Latino White(Caucasian) Other

Have you hiked before? (Re'qd by HSVTC) *
<---- Select One ----> Yes No

Do you have any Physical limitations we should know about

Do you have medical insurance ? *
<---- Select One ----> Yes No

Age *
<---- Select One ----> Under 14 years 14-17 18-24 years 25-30 years 31-54 years 55 years and above

Is this your first trip with HSVTC ? *
<---- Select One ----> Yes No

Emergency Contact - First Name *

Emergency Contact - Last Name *

Emergency Contact Phone *

Emergency Contact Relationship *
<---- Select One ----> Family Member Friend Colleague or classmate Other

Check the box below to indicate that you have reviewed and agree with our Risks and Hazards *

Check the box below to indicate that you have reviewed and agree with our Risks and Hazards *

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