CHICKS WITH PICKS - www.chickswithpicks.net

CHICKS WITH PICKS SIGN UP FORM: Print out and mail in with your deposit.

PLEASE NOTE: The balance is due 30 days before the clinic date.
Make checks payable to: Freelance Adventures Inc/CWP
Mail checks and registration form to:

USPS MAIL	UPS/DHL/FEDEX
Chicks with Picks, c/o Kim Reynolds, PO Box 486 Ridgway, CO 81432	Chicks with Picks, c/o Kim Reynolds, 546 Hyde St Ridgway, CO 81432

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.

CHICKS WITH PICKS ICE CLIMBING CLINIC SIGN-UP & QUESTIONNAIRE
(please fill this out and send in with your deposit!)

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

PERSONAL INFORMATION:

Name: _______________________________________________________________

Address: _____________________________________________________________

City: _____________________________ State: ____ Zip Code: _______________

Country: ______________________________________________________________

Phone number: (work)______________________(home)______________________

Email Address:_________________________________________________________

Age: _______ Birth date:____________

Occupation:___________________________________________________________

T-shirt size: ____________________________ Shoe size:_____________________

Height: __________________________ Weight: ____________________________

PRICING INFORMATION AND CLINIC CHOICE: Our listed price is for double occupancy to keep your costs down. Single rooms are upon request, they are limited and more expensive. We recommend staying in our designated Hotel/Inn since we base all activities from there and the hotels give us the best deal in town. Remember, price includes everything … once you arrive.
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!
The totally chicks (2 to 1 ratio) (5 nights, 4 climbing days)	_____	$1650 (double occupancy) = $825 non-refundable deposit
	_____	$1850 (single room) = $925 non-refundable deposit
	_____	$1500 (no hotel) =$750 non-refundable deposit

The Complete (4-to-1 ratio) (5 nights, 4 climbing days)	_____	$1350 (double occupancy) = $675 non-refundable deposit
The Complete (4-to-1 ratio) (5 nights, 4 climbing days)	_____	$1550 (single room) = $775 non-refundable deposit
	_____	$1200 (no hotel) = $600 non-refundable deposit

The Sampler (4-to-1 ratio) (3 nights, 2 climbing days)	_____	$976 (double occupancy) = $488 non-refundable deposit
The Sampler (4-to-1 ratio) (3 nights, 2 climbing days)	_____	$1096 (single room) = $548 non-refundable deposit
	_____	$886 (no hotel) = $443 non-refundable deposit

Chicks East (4-to-1 ratio) (4 nights, 3 climbing days)	_____	$1076 (double occupancy) = $538 non-refundable deposit
Chicks East (4-to-1 ratio) (4 nights, 3 climbing days)	_____	$1316 (single room) = $658 non-refundable deposit
	_____	$896 (no hotel) = $448 non-refundable deposit

East Teaser (4-to-1 ratio) (2 nights, 1.5 climbing days)	_____	$650 (double occupancy) = $325 non-refundable deposit
East Teaser (4-to-1 ratio) (2 nights, 1.5 climbing days)	_____	$770 (single room) = $385 non-refundable deposit
	_____	$560 (no hotel) = $280 non-refundable deposit

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_________________

Phone number (day)____________________ (night)_________________

INSURANCE INFORMATION:
There are inherent risks involved in ice climbing. We highly recommend that you obtain health insurance prior to participating.

Carrier ______________________________policy #_________________

Phone number________________________________________________

Address_____________________________________________________

State____________ Zip code_______________ Country_____________

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: __________

Flight # ________

Departure Date: _________ Depart. Time: _________ Airline: ________ 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? Circle one:

excellent, above average, average, fair, poor

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?