Learn to ice climb at Chicks with Picks women's ice climbing clinics in Ouray, Colorado

TO SIGN UP ONLINE FOR A CHICKS WITH PICKS CLINIC:
Fill out the online form below. Remember, registration is on a first-come-first-serve basis, and will be determined by the date received. If you are serious about attending, we recommend that you get your deposit in early. In order to reserve your space, our policy strictly states that your deposits are NON-REFUNDABLE. Thank you.

ANY QUESTIONS:
Please call: Kim Reynolds at 970-626-4424
E-mail: info@chickswithpicks.net

CHICKS WITH PICKS ICE CLIMBING CLINIC SIGN-UP & QUESTIONNAIRE
STEP 1: Fill out Personal, Medical, Insurance & Fitness Information
STEP 2: Select the Clinic of interest by filling in a number next to the clinic.
STEP 3: Fill in Billing information and Credit card info on the secure page.

Please read the CLINIC LEVELS page before filling out this form.

PERSONAL INFORMATION :
Name:			Email:
Address 1:			Age:
Address 2:			Birthday:
City:			Tshirt Size:
State:			Shoe Size:
Zip:			Occupation:
Home Phone:			Height:
Work Phone:			Weight:

I would like to sign up for the following clinic: (PLEASE CHECK ONE) The following choices are for all clinics: Please read the CLINIC LEVELS before choosing!
	TOTALLY CHICK (4-1 RATIO)
	THE COMPLETE (4-1 RATIO)
	THE SAMPLER (4-1 RATIO)
	CHICKS EAST (4-1 RATIO)
	EAST TEASER (4-1 RATIO)

I would like to sign up for the following level: (PLEASE CHECK ONE) The following level choices are for all clinics:
	#1 LEARNING THE BASICS
	#2 HONING SKILLS AND PROGRESSING
	#3 VERTICAL ICE FOCUS
	#4 MIXED CLIMBING
	#5 ADVANCED SKILLS AND LEAD CLIMBING

SKILLS DAY: Write your #1, #2 and #3 choice. We need at least three participants to run a workshop, it is possible you will get your second or third choice. The following choices are for the "Complete Chicks Clinic" only. Please read the CLINIC LEVELS before choosing!
	#1 RESCUE WORKSHOP
	#2 MIXED CLIMBING TECHNIQUE
	#3 ALPINE SKILLS AND AVALANCHE AWARENESS
	#4 ICE CLIMBING

EMERGENCY CONTACT INFORMATION:
Name:			Relationship to you:
Day Phone:			Night Phone:

INSURANCE INFORMATION:
Carrier:			Policy #:
Phone Number:			Address:
State:			Zip Code:

TRAVEL INFORMATION: We are not responsible for cancellation fees or costs arising from your changed or cancelled flights, lodging, or other arrangements. We recommend obtaining trip cancellation insurance from your travel agent.
Airport:			Arrival Time:
Airline:			Arrival Flight #:
Departure Date:			Departure Time:
Airline:			Departure Flight #:

MEDICAL INFORMATION: We recommend that you consult your physician regarding your participation in one of our ice climbing clinics. Please contact us if you have ANY questions regarding your ability to participate.

Do you have any medical conditions or limitations? If so, Please explain:

Are you taking any medications? Please list and explain.

Do you have any past or present injuries? If so, explain.

Are you pregnant? If so, how many months?

Do you have any food allergies or restrictions? If so, what are they?

Are you a vegetarian?

FITNESS INFORMATION: To fully enjoy and benefit from our clinics, we recommend an average level of fitness or above. Consult with your physician if you have any concerns.
What kind of physical condition are you in? Check one:
	Excellent	Fair
	Above Average	Poor
	Average

Please list the activities in which you participate in and the frequency of each activity.

OTHER QUESTIONS:

1) Please describe your previous ice climbing experience.

2) How many years have you ice climbed?

3) How many days total?

4) Where have you climbed?

5) List some climbs you've followed and their difficulty.

6) What difficulty ice have you led and how many? Please list climbs and the difficulty of the one's you have led.

7) What interests you most about the clinic?

8) What would you like to focus on?

9) Do you any rock climbing experience? Please explain.

10) Do you have any alpine climbing experience? Please explain.

11) How did you learn about the clinic?

12) If you are an alumni, please list the year, guide and class level you participated in.

13) We will have limited demo gear available for you to use though we suggest that you bring your own gear if you have it. Please list the gear you do NOT have (example: ice axes, crampons, boots, back pack or soft wear ). (see What to Wear page for specifics)

14) Do you have any concerns you would like to express?

15) Is there anything else you want to comment on?

PLEASE NOTE: The balance is due 30 days before the clinic date.
Reservation Policy
A non-refundable deposit for half the amount of the clinic cost is due at the time of booking. The balance is due 30 days prior to the clinic date. If you register within 30 day’s of the clinic, the full amount is due upon registration.

Cancellation Policy
30 days or more before clinic: Half of full tuition will be refunded.
Between 14 and 30 days before clinic: One quarter of full tuition will be refunded.
14 days or less before clinic: No tuition will be returned.
Please Note: We are sorry but no exceptions will be granted from this policy, including injury, illness or family emergencies.

* We highly recommend that you obtain travel insurance to recover your deposit and/or flight if you have an unexpected life occurrence and cancel.