Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number of Childcaren *

1

2

3

4

5+

Are you currently pregnant? *

Yes

No

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Authorization for Release of Information *

I hereby understand and agree that I am committing to the above costs, travel plans, accommodations, food, and agenda by applying.

I hereby understand and agree that payment one, a $50 deposit, and payment two, $350 (train) or $450(plane), are non-refundable.

I hereby understand and agree that childcare is NOT provided and that I am solely responsible for ensuring my child(ren) are safely cared for while I am away.

I hereby understand and agree that I am responsible for all costs associated with traveling to the train station or airport from my home and for any food or other costs associated with traveling by train or plane.

I hereby agree that I will physically train before this trip and be able to walk multiple miles uphill and jog up to one mile without labored breathing.

I hereby understand and agree that Single MOMM, its staff, or volunteers are not medical professionals. All health checks on the mountain will be done by non-medical professionals and are not to be in any way a guarantee that you are healthy to climb.

I hereby understand and agree that I will receive a health check at the base camp on Pikes Peak, and if I do not pass the check, I will not be allowed to continue climbing the mountain. I will descend the mountain with a Single MOMM guide, and I may or may not be able to reach the top by the COG railway.

I hereby understand that if I need to be taken off Pikes Peak by medical personnel, helicopter, or any other means, these expenses are my full responsibility, and my insurance may or may not cover these costs.

I hereby release Single MOMM from any and all liabilities. I understand and agree that I am participating and climbing at my own risk.

I hereby understand and agree that by participating or climbing, I may experience sickness, bodily injury, mental fatigue, emotional distress, or even death. I agree to hold Single MOMM, its staff, and volunteers are not responsible for any of these experiences.

I hereby understand and agree that Single MOMM, its staff, and volunteers are not medical, legal, or mental health professionals.

I hereby give authorization and permission for Single MOMM to exchange or release information regarding my well-being.

I hereby give authorization and permission for Single MOMM to call medical personnel on my behalf and understand that the cost for the medical personnel will be my sole responsibility.

I hereby understand and agree to The Code of Conduct:

I will seek to speak kindly and not engage in foul, mean, or degrading language towards another person.

I will respect the confidentiality and stories of others.

I will seek to be a voice of encouragement.

I will seek to fuel my body with healthy food, drinks, and nutrients. I will not drink alcohol, smoke marijuana, or take any illegal or recreational drugs.

I will seek to build friendships and abstain from any romantic relationships or sexual encounters while attending camp.

I will respect the Single MOMM staff, volunteers, and guides.

I will adhere to the rules and laws of the camp, rental companies, airports, train stations, National Forest, and Cities

I understand that I am representing Single MOMM and will seek to be The Good Coffee (Single MOMM core value).

I, the undersigned, hereby acknowledge that I have read/understand this information prior to its execution and fully understand the nature of this consent *

By checking this box and typing my name below, I am electronically signing my application

Date *

MM

DD

YYYY