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Backtrackers                       Application                Waiver >
75 Plantation Rd.                     (1 of 2)                 
Martinsville, VA  24054

This information is solely for the understanding of Backtrackers, Will Franck. All information will be held in strict
confidence and, to the extent of the law, will not be released to anyone without your prior consent.

General Information:
Class Dates: __________________

Name: __________________________________________________________

Address: ___________________________________________________

            ___________________________________________________ ZipCode _______________

Home Phone: ____________________________    Work Phone: ____________________________

Male____ Female____           Age:______

In case of emergency, please contact:

Name: __________________________________________ Relationship:______________

Phone: (home)____________________________ (work)____________________________

Medical History:
Are you currently taking any prescription medications? If so, please list medication and condition:


List any allergies to medication:


List any food allergies or other allergies (including adverse reactions to bee stings):


Check if you have had any significant history of the following (circle if current):
____ Heart disease                  ____ Hyper/Hypoglycemia     ____ Diabetes
____ High blood pressure       ____ Asthma

Is there any medical or physical condition not listed here that could impact your participation
in this program that we should know about? Please describe:

Signature: ___________________________________________________  Date: ___________