(Fill with honesty and click)
Canyoner
Name:
Surname:
Occupation:
E-mail:
Address:
Zip Code:
Country:
Home phone:
Mobile phone:
Age:
Gender:
Facebook:
Instagram:
LinkedIn:
Website:
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Emergency contact person
Name:
Surname:
Relationship:
Home phone:
Mobile phone:
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Canyoning Experience
1. Beginner 0 – 10 descents
No experience at all [ ]
Introduction to canyoning course [ ]
Introduction to canyoning with friends [ ]
2. Experienced I 20 – 60 descents
Without certification by a canyoning course [ ]
SFP1 [ ]
Level1 [ ]
3. Experienced II 60 – No limit descents
Without certification by a canyoning course [ ]
SFP1 / SFP2 [ ]
Level1 / Level2 [ ]
3. Expert / Guide / Pro 200 – No limit descents
Without certification by a canyoning course [ ]
SFP2 / Level2 [ ]
Level Initiateur [ ]
Level Moniteur [ ]
Level Instructeur [ ]
Professional Guide [ ]
Professional Canyoning Rescuer [ ]
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Medical Form
Skin diseases [ ]
Allergies [ ]
Heart disease [ ]
Respiratory Diseases [ ]
Epilepsy [ ]
Recent Cancer Treatment [ ]
Hepatitis A, B, C [ ]
HIV/AIDS [ ]
Diabetes [ ]
Psychiatric Disorder [ ]
Pregnancy [ ]
Musculoskeletal Diseases [ ]
Other [ ]
Do you have any of the following symptoms?
Love yourself and get a checkup J
Chest pain [ ]
Respiratory [ ]
Cardiovascular [ ]
Hematology [ ]
Lymphatic [ ]
Neurological [ ]
Psychiatric [ ]
Gastrointestinal [ ]
Genitourinary [ ]
Other [ ]
Have you recently had Covid?
No [ ]
Yes [ ]
Are you currently taking any medication?
No [ ]
Yes [ ]
Please list them:
How often do you consume alcohol?
Daily [ ]
Weekly [ ]
Monthly [ ]
Occasionally [ ]
Never [ ]
Are you a smoker?
No [ ]
Yes [ ]
Occasionally [ ]
Are you a doctor / nurse?
No [ ]
Yes [ ]
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