Pre-Clinic Participant Information

PARTICIPANT INFORMATION

Please fill out the following form as detailed as possible. Information provided will be treated with the strictest confidentiality. Any vague or incorrect information could result in injury or death of yourself or other participants.

Participant First and Last Name *

Personal Pronouns

Example: he, she, they

Participant Date of Birth *

Participant Phone Number *

Participant Email *

Medical Insurance Company & Insurance Policy Number

I acknowledge H2o Dreams LLC personal liability policy.

EMERGENCY CONTACT INFORMATION

In the event of an emergency, please provide contact information for an emergency contact.

Emergency Contact *

Relationship to Particpant *

Example: spouse, partner, parent, friend, etc.

Emergency Contact Phone Number *

Emergency Contact Email *

VITAL INFORMATION

Please answer the following questions to the best of your ability. This information helps your instructor(s) prepare for your participation in our course(s) and provide the best possible experience.

Height *

Weight *

Will you have completed full Covid-19 vaccination prior to the start of your course dates? *

Yes

This does not affect your eligibility for participation.

Are you currently undergoing treatment for any medical condition / illness? *

Yes

If yes, please describe:

Are you currently taking any form of medication? *

Yes

If yes, please describe:

Have you had any injuries or undergone surgery in the past? *

Yes

If yes, please describe:

Do you have any allergies? *

Yes

If yes, please describe:

Do you or anyone in your family have a history of heart-related problems? *

Yes

If yes, please describe:

Have you ever experienced any heat and/or cold related illness/injuries? *

Yes

If yes, please describe:

Can you swim? *

Yes

Do you wear eyeglasses or contacts? *

Yes

Do you smoke? *

Yes

Do you have any dietary restrictions? *

Yes

If yes, please describe:

Is there any other medical related or personal information you would like for us to know?

PRE-CLINIC STUDENT EXPERIENCE ASSESSMENT

This is an elective section for additional information to help develop your instructional experience with H2o Dreams and guide your placement in our programs. If you have had previous experiences on whitewater, we recommend taking time to answer the questions below thoughtfully. If you are new to paddling or otherwise feel that you cannot answer the questions below, feel free to leave blank.

Have you ever had any formal instruction?

Yes

If yes, where did you receive instruction, and how much instruction have you had? If no, how did your paddling skills get to where they are today?

Have you taken a swiftwater rescue class in the past year?

Yes

Some of our courses require additional rescue and training skills as you are expected to be an active part of the group safety.

Do you have First Aid / CPR training?

Yes

Some of our courses require additional rescue and training skills as you are expected to be an active part of the group safety.

How often do you paddle? About how long do you paddle during each outing?

What rivers do you regularly paddle?

Do you run all the main lines/rapids? Do you explore new lines?

Describe your most challenging day of paddling. What was the quality of that experience?

Describe your paddling group. What is your role within that group?

What equipment do you carry with you while paddling?

Please be thorough! Use this space to detail what gear you will bring with you for class as well as any equipment needs you may have from H2o Dreams.

At what skills do you excel? What skills need work?

When was the last time you had a combat roll (an unplanned roll on the river)? When was the last time you had a swim? Describe what led to those experience(s).

Self-Rescue

Self-rescue is defined as a safe, controlled wet-exit and recovery of equipment to shore.

Rolling Ability

Rolling Variability

How comfortable are you with dynamic inversion?

Your kayak is flipped dynamically and unexpectedly and the environment is cold, dark, shallow, or turbulent.

Rate yourself 1-5 on the skills below. 1 being the least developed and 5 being the pinnacle.

Overall river and group awareness

Scouting from shore

Scouting from boat

Receiving beta (info about rapids/lines)

Giving beta

Identifying hazards

Ability to see lines and execute

Read and run whitewater

Controlling pitch, spin, and roll of the kayak

Knowledge and use of basic strokes and biomechanics

Compound strokes

Catching small eddies

Catching powerful eddies

Use of features for deliberate movement on the river

Boofing technique (various styles and applications)

Intentional surfing

Unintentional surfing

How do you deal with fear and intimidation?

Have you ever had a traumatic experience, gone blank, not remembered, or had any setbacks - paddling or otherwise - that may be complicating success and enjoyment on the river?

By submitting this form, I certify and acknowledge that I have read this document thoroughly and that all the information I have provided is correct and accurate. *

I agree.

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PARTICIPANT INFORMATION

EMERGENCY CONTACT INFORMATION

VITAL INFORMATION

PRE-CLINIC STUDENT EXPERIENCE ASSESSMENT

Rate yourself 1-5 on the skills below. 1 being the least developed and 5 being the pinnacle.

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