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Exodus

The Holy Cross Expedition

Through The Wilderness… a Journey to Holiness

August 6-14, 2017

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Blueprint for Men, Inc. 2017 ©

Holy Cross Expedition Through the Wilderness… a Journey to Holiness

August 6-14, 2017

Greetings Mountain Men,

John Muir once penned the motivational quote… “The mountains are calling and I must go.” And while I wholeheartedly agree with Muir, I more deeply sense that we are responding to the “Still Small Voice”, the heart of God calling us upward to high places. And when God calls we must answer, for to do so is to embark on an adventure like no other! Through the mountain wilderness Moses, Elijah, and Jesus were all faced with the holiness and power of God. That is our goal and our deepest desire. Pray for nothing short of this my friends and be ready for what God has in store… it’s sure to be awesome! The following information packet contains the essential details for your participation in this expedition. Please carefully read this document to make sure you follow the preparation timeline below. Preparation Timeline:

Step 1 Now Begin a fitness program and acquiring gear

Step 2 June 25 Begin the EXODUS Curriculum

Step 3 June 25 First ZOOM Conference call Step 4 July 16 Sign-up Deadline

Step 5 Aug 6-14 Holy Cross Expedition

If you have any questions feel free to call, text, or email. Let’s climb!

Marty Miller Blueprint for Men

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INFORMATION PACKET TABLE OF CONTENTS

1. Overview 2. Leadership 3. Schedule 4. Gear List 5. Logistics 6. LNT 7. Forms

1 OVERVIEW

WHO: Young men participating in the EXODUS WHAT: The culminating wilderness experience to the EXODUS journey to freedom WHERE: Holy Cross Wilderness, Colorado PROVIDED: Trip leadership, naturalist education, spiritual guidance, transportation, etc. BRING: You are responsible for your own camping equipment…refer to equipment list REGISTRATION: Every participant must complete and submit the following forms

Participant Form - send PDF copy via email to blueprint4men@gmail.com

Release Form – send PDF copy via email to blueprint4men@gmail.com

Medical Form – send PDF copy to blueprint4men@gmail.com COST: Donation of $100 – make donation at www.blueprintformen.org SIGN-UP: July 14, 2017 Deadline OBJECTIVES: Purification and Holiness

Walking with God in Quiet Solitude Brotherhood of Suffering Servant Leadership

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2 LEADERSHIP

Marty Miller, Expedition Leader Marty is a lifelong disciple of Christ, the loving husband of his first wife, the father of two adult children, and the proud grandfather of two grand-daughters. Marty’s career path has been primarily in the field of education having served in both public and private sectors from California to Tennessee. He has held positions that include elementary school principal, multi-grade teacher, middle school science teacher, high school science teacher, nature center director, outdoor school director, educational consultant, university education professor, student teacher supervisor, and outdoor leadership program director.

He is a well-recognized outdoor professional with skills and certifications that include WMI/NOLS Wilderness First Responder, ACA Swift Water Rescue, and AIARE Avalanche Safety. Marty is gifted at discovering and sharing spiritual lessons from nature, God’s second book, as modeled by Jesus Christ, the master educator. Now, after nearly 30 years in education, Marty has transitioned into full-time ministry by creating Blueprint for Men, a non-profit men’s ministry devoted to helping men discover and live out their God-given design in a secular world. Through outdoor retreats, small group support, leadership training, and curriculum development, Marty is helping men to step up and become the men God intended them to be, better husbands, better fathers, and better disciples of Christ! “Leader of the Day” During the trek each man will have an opportunity to provide leadership for the entire group in what we call “Leader of the Day”. During your leadership day you will guide and manage the group as pertaining to safety, schedule, teaching, devotionals, etc. Oversight will be provided by the trip leader, Marty Miller, but just enough to ensure that our objectives are met. While on the trek we will follow the Biblical pattern of the day starting at sundown so your leadership day will begin in the evening too! This will all make sense while on the trip… I promise!

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3 SCHEDULE

Date Tentative Schedule Sun, Aug 6 Leave Southern

Drive to Denver

Mon, Aug 7 Arrive in Denver REI Food purchases Drive to Half Moon Campground Set up camp Supper Evening Group Worship Anointing - Hyssop - Purification & Empowerment

Tue, Aug 8 Leader of the Day Breakfast Morning Group Worship Backpack 2.0 miles to campsite Supper Evening Group Worship Anointing - Frankincense and Myrrh - Healing / Intercession

Wed, Aug 9 Leader of the Day Sunrise Climb (4.8 miles RT) to Notch Mountain Shelter (13,077’) Breakfast Morning Group Worship Backpack 1.5 miles to Lake Constantine (11,300’) Supper Evening Group Worship Anointing - Cinnamon - Passion & Courage

Thu, Aug 10 Leader of the Day Breakfast Morning Group Worship Basecamp – Activities TBD Backpack 1.6 miles to Tuhare Lake (12,300’) Supper Evening Group Worship Anointing - Cedars - Strength & Protection

Fri, Aug 11 Leader of the Day Sunrise climb (4.0 miles) of Mount of the Holy Cross (14,005’) via Holy Cross Ridge Breakfast Morning Group Worship Supper – (Communion) Evening Group Worship Anointing - Spikenard - Worship & Praise

Sat, Aug 12 Leader of the Day Breakfast Morning Group Worship Backpack to trailhead Evening Group Worship Drive to Glacier View Ranch Celebration Supper

Sun, Aug 13 Drive Home

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4 GEAR LIST General Backpacking & Camping Gear

o Large backpack (65L+) o Sleeping bag (rated to a min. of 30° F) o Sleeping pad o Lightweight Tent o Stove w/fuel o Cook-set o Lighter/matches o Cooking Utensils o 1 liter wide-mouth water bottles (2) o Zip-lock bags for stuff o Compass & map

Clothing

o Trail boots o Waterproof/breathable jacket and pants o Fleece insulating layer o Insulating jacket o Quick-dry synthetic underwear (2) o Quick-dry synthetic T-shirt (2) o Warm gloves o Wool socks (2) o Warm cap

Personal First aid kit

o Band-Aids o Duct tape o Moleskin o Ace bandage o Athletic tape o Scissors o Antibiotic ointment o Aspirin /Tylenol – for headaches o Aleve/Ibuprofen – for swelling o Prescriptions

Misc. Personal Items

o Sunglasses o Sunscreen (SPF 30+) o Lip balm o Headlamp o Extra batteries o Ear plugs for tent flap wind noise o Toilet paper in Ziplock bag o Deodorant o Pack towel for bathing o Bible o Journal o Pen/pencil

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5 LOGISTICS Financial Transportation and the “wilderness experience” are all provided for free. Each person is responsible for paying for their own gear, food, and other incidentals.

Transportation

SAU 12 passenger van and trailer

Communication

Much of the backcountry is out of cell phone service range. That being said it is possible that some high points may have a signal. I will bring a lightweight solar panel into the backcountry to charge phones, etc. via USB cable since you might use them as cameras and such.

Safety

I have medical training as a Wilderness First Responder and will be carrying a group first aid kit. Please bring your own personal first aid kit as listed in the gear section. In the event of a major medical emergency that requires helicopter evacuation I will be carrying a SPOT (satellite messenger) with up to $100,000 evacuation insurance.

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Half Moon Campground – Elevation 10,000’+

General Information

Directions: Travel west on I-70 to Exit 171 for Minturn, Leadville, and Hwy 24.Turn right and travel south about 5 miles. Immediately before crossing the Eagle River, turn right onto Tigiwon Road - FSR 707 and continue up this dirt road for 8 miles to the campground at the end. Reservations: first come first served Fees: $13/night

**Bear activity has been increasing. For this reason a food storage order is in

effect at all developed campgrounds on the Eagle/Holy Cross Ranger District,

and the Piney Guard Station, Tigiwon Lodge, Mount of the Holy Cross Overlook,

Homestake Road FSR 703, and Nolan Creek Road. This order requires all food

and refuse to be stored in hard-sided vehicles, approved bear-resistant

containers, or suspended at least 10 feet clear of the ground at all points and

four feet horizontally from any supporting tree or pole. This order has been issued to provide for public safety and

wildlife conservation. Hopefully it will reduce wildlife habituation problems.**

The Halfmoon Campground is located at the top of Tigiwon

Road #707 near the boundary for the Holy Cross Wilderness in

a forested setting; all wilderness regulations must be

observed when traveling in the wilderness (foot and horse

travel only). This campground is located at the trailheads for

several hiking trails and is heavily used by hikers who are

climbing Mount of the Holy Cross.

Due to the nature of the Forest Road to the campground and

the short parking spurs within the campground, the Halfmoon Campground is not suitable for most RVs.

Sitka Valerian Paintbrush Colorado Columbine Sky Pilot

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Holy Cross Wilderness

The Holy Cross Wilderness is a U.S. Wilderness Area located in San Isabel and White River national forests

near Leadville, Minturn, Avon, Edwards, Eagle, and Vail, Colorado. The 122,797-acre (496.94 km2) wilderness with

164 miles (264 km) of trails was established in 1980. The wilderness was named after its highest peak, 14,005-foot

(4,269 m) Mount of the Holy Cross.[2]

The Holy Cross Wilderness has a history of many hikers, often those who are unprepared, becoming endangered.

Primarily, the hikers who require rescue are unfamiliar with the risks of entering wilderness areas and do not bring

adequate equipment and supplies to respond to emergency conditions. Hikers are frequently stranded or lost due

to changing environmental conditions and confusion regarding the surrounding landscape. Holy Cross Wilderness

visitors should carry adequate provisions, the ten essentials, including water, food, firestarter, guide book

or map, global positioning device, layers of clothing, headlamp, knife, and cell telephone. Thorough research and

reasonable planning should prevent most tragedies.[3][4]

Holy Cross Wilderness hiking trails include Nolan Lake Trail, Lake Charles Trail to Lake Charles and Mystic Island

Lake, New York Mountain Trail, Dead Dog Trail, Middle Lake Trail, Beaver Lake Trail to Beaver Lake and Turquoise

Lake, Fancy Lake Trailhead in person (or Fancy Creek Trailhead as the maps say) Grouse Lake Trail, West Grouse

Creek Trail, Martin Creek Trail, Notch Mountain Trail, Half Moon Pass Trail to Mount of the Holy Cross, Tuhare

Lakes Trail, and Cross Creek Trail to Treasure Vault Lake and Blodgett Lake. Holy Cross Wilderness Area: Northern

Trails of Eagle County, a hiking guide by Kim Fenske, describes these trails.[5]

East Zone/Holy Cross Ranger District 24747 US HIGHWAY 24 MINTURN, CO 81645

Phone: 970-827-5715 Email: Not available

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Backpack Trip – Tuhare Lakes (11.2 miles RT)

The Tuhare Lakes are located 5.6 miles (2,000’+ elevation

gain) from Tigiwon Road in the Holy Cross Wilderness. The

upper lake occupies a massive cirque carved from the Holy

Cross Ridge, and the lower lake is 275' below in a scenic

alpine terrace. Upper Tuhare Lake (12,365') is notably large

for a lake at this elevation.

The Fall Creek Trail runs high along the west valley wall before opening in the upper valley at Lake Constantine,

past which the Tuhare Lakes Trail splits off on a strenuous climb to the lakes. Visitors will enjoy excellent fishing,

scenic waterfalls and imposing alpine backdrops on the hike to the Tuhare Lakes:

The trail begins on a moderate grade in a thick subalpine forest. It dips at 1.3 miles (10,840’), the first of several

subtle drops that add up on the return. Timber breaks here on a steep slope with good views across Fall Creek and

distant peaks in the Gore and Ten Mile ranges.

Walk through a stream that bisects the trail at 1.52

miles and resume steady travel past interesting rock

features to the Notch Mountain Trail split (2.34

miles : 11,225’).

The Fall Creek Trail continues SW on mild-moderate

undulations to the base of a talus slide and meadow

(3.5 miles : 11,240’). It steepens away into the upper

valley where the landscape opens to rolling alpine

meadows and Lake Constantine (3.95 miles:

11,371’).

Lake Constantine is a compelling destination in itself, with exceptional fishing and ideal camping terrain. The trail

fades and splits through damp meadows around the lake, but clarifies on higher ground on the west side.

The trail undulates past Constantine in a thinning forest to the Tuhare Lakes Trail split (4.55 miles : 11,505’). The

Tuhare Lakes Trail splits west and clears treeline on a steep, twisting climb beside the lower lake’s outlet falls.

Some hand-over-hand scrambling is required on this segment.

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It levels briefly with a great look at the waterfall (4.95 miles),

then presses steeply right beside it to Lower Tuhare Lake (5.2

miles : 12,090’). Talus or snow may obscure cairns but the route

is fairly obvious. The lake fills a scenic alpine terrace with thick

grasses, large boulders and a diverse collection of flowers.

The intermittently defined trail continues along the north shore

and scales rugged terrain beside the waterfall's upper tier. The

falls are spectacular, but avoid adjacent rock slabs that can be

perilously slick.

The landscape will naturally funnel you (left)

across the top of the waterfall to Upper

Tuhare Lake (5.6 miles: 12,365’). Note the

route you took, as it may be difficult to

retrace. Upper Tuhare Lake is massive, and

ringed by jagged 13,000’+ peaks of the Holy

Cross Ridge. Scan slopes above for mountain

goat and bighorn sheep, which are common

in this area.

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TRAIL MAPS

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1: N39 30.018 W106 25.973 — 0.0 miles : Fall Creek Trailhead

2: N39 29.619 W106 26.012 — .5 miles : Fast travel in a thick forest

3: N39 29.256 W106 26.164 — 1.0 miles : Rocky-rooted path on moderate grade

4: N39 28.863 W106 26.241 — 1.5 miles : Dip and cross stream that bisects trail

5: N39 28.481 W106 26.467 — 2.0 miles : Occasional breaks in timber with views

6: N39 28.260 W106 26.563 — 2.34 miles : Notch Mountain Trail split

7: N39 27.888 W106 26.734 — 2.85 miles : Mild-moderate undulations into upper valley

8: N39 27.481 W106 27.182 — 3.5 miles : Trail opens in first subalpine meadow

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9: N39 27.162 W106 27.352 — 3.95 miles : Lake Constantine (11,371')

10: N39 26.802 W106 27.698 — 4.55 miles : Fall Creek - Tuhare Lakes Trail split (11,505')

11: N39 26.977 W106 28.165 — 5.2 miles : Lower Tuhare Lake (12,090')

12: N39 26.986 W106 28.488 — 5.6 miles : Upper Tuhare Lake (12,365')

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Notch Mountain Shelter Hike – 10.4 miles

Round-Trip Length: 10.4 miles

Start-End Elevation: 10,325' - 13,077' (Notch Mountain Shelter)

Elevation Change: +2,752' net elevation gain (+2,955' total roundtrip elevation gain)

1: N39 30.018 W106 25.973 — 0.0 miles : Fall Creek Trailhead

2: N39 29.619 W106 26.012 — .5 miles : Fast travel in a thick forest

3: N39 29.256 W106 26.164 — 1.0 miles : Rocky-rooted path on moderate grade

4: N39 28.863 W106 26.241 — 1.5 miles : Dip and cross stream that bisects trail

5: N39 28.481 W106 26.467 — 2.0 miles : Occasional breaks in timber with views

6: N39 28.260 W106 26.563 — 2.34 miles : Notch Mountain Trail split

7: N39 28.260 W106 26.563 — 2.34 miles : Notch Mountain Trail split

8: N39 28.353 W106 26.826 — 2.95 miles : Trail crosses big open slope

9: N39 28.228 W106 26.889 — 3.25 miles : Clear balance of treeline

10: N39 28.176 W106 26.997 — 3.45 miles : Pass through 12,000'

11: N39 28.285 W106 27.188 — 3.95 miles : Begins series of switchbacks through talus

12: N39 28.269 W106 27.366 — 4.5 miles : Steady climb on switchbacks

13: N39 28.249 W106 27.491 — 5.0 miles : Approach 13,000'

14: N39 28.174 W106 27.558 — 5.2 miles : Notch Mountain Shelter

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MOUNT OF THE HOLY CROSS (14,005’) 12.5 MILES 5,980’ ELEVATION GAIN

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WEATHER

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6 LNT… LEAVE NO TRACE BACKCOUNTRY ETHICS

The Leave No Trace Seven Principles The Leave No Trace Seven Principles are the bedrock of the Leave No Trace program. They provide guidance to enjoy our natural world in a sustainable way that avoids human-created impacts. The principles have been adapted to they can be applied in your backyard or your backcountry.

Plan Ahead and Prepare Know the regulations and special concerns for the area you'll visit.

Prepare for extreme weather, hazards, and emergencies.

Schedule your trip to avoid times of high use.

Visit in small groups when possible. Consider splitting larger groups into smaller groups.

Repackage food to minimize waste.

Use a map and compass to eliminate the use of marking paint, rock cairns or flagging.

Travel and Camp on Durable Surfaces Durable surfaces include established trails and campsites, rock, gravel, dry grasses or snow.

Protect riparian areas by camping at least 200 feet from lakes and streams.

Good campsites are found, not made. Altering a site is not necessary.

In popular areas:

Concentrate use on existing trails and campsites.

Walk single file in the middle of the trail, even when wet or muddy.

Keep campsites small. Focus activity in areas where vegetation is absent.

In pristine areas:

Disperse use to prevent the creation of campsites and trails.

Avoid places where impacts are just beginning.

Dispose of Waste Properly Pack it in, pack it out. Inspect your campsite and rest areas for trash or spilled foods. Pack out all trash, leftover food and

litter.

Deposit solid human waste in cat holes dug 6 to 8 inches deep, at least 200 feet from water, camp and trails. Cover and disguise the cat hole when finished.

Pack out toilet paper and hygiene products.

To wash yourself or your dishes, carry water 200 feet away from streams or lakes and use small amounts of biodegradable soap. Scatter strained dishwater.

Leave What You Find Preserve the past: examine, but do not touch cultural or historic structures and artifacts.

Leave rocks, plants and other natural objects as you find them.

Avoid introducing or transporting non-native species.

Do not build structures, furniture, or dig trenches.

Minimize Campfire Impacts Campfires can cause lasting impacts to the backcountry. Use a lightweight stove for cooking and enjoy a candle lantern for

light.

Where fires are permitted, use established fire rings, fire pans, or mound fires.

Keep fires small. Only use sticks from the ground that can be broken by hand.

Burn all wood and coals to ash, put out campfires completely, then scatter cool ashes.

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Respect Wildlife Observe wildlife from a distance. Do not follow or approach them.

Never feed animals. Feeding wildlife damages their health, alters natural behaviors, and exposes them to predators and other dangers.

Protect wildlife and your food by storing rations and trash securely.

Control pets at all times, or leave them at home.

Avoid wildlife during sensitive times: mating, nesting, raising young, or winter.

Be Considerate of Other Visitors Respect other visitors and protect the quality of their experience.

Be courteous. Yield to other users on the trail.

Step to the downhill side of the trail when encountering pack stock.

Take breaks and camp away from trails and other visitors.

Let nature's sounds prevail. Avoid loud voices and noises.

Properly Storing Attractants in Bear Country

Generally Bears have a broad diet and are attracted to a wide variety of unnatural foods, including human food, garbage, canned or bottled beverages, processed livestock feed, pet food, bird seed, toiletries, and coolers, stoves, and grills containing food or food residue.

Bears that obtain human food or garbage often become aggressive and dangerous in their efforts to get more. This food‐conditioned behavior can lead to human injury, death, and damage to property.

Food‐conditioned behavior usually cannot be changed and these bears must be killed by managers.

Don’t be the one responsible for human injury or death or the death of a bear because YOU did not store your food properly.

Read and understand food storage regulations before your visit. Coolers, backpacks, wooden boxes, and tents are not bear resistant and may not be used to store food or other bear attractants.

For more bear safety tips, visit the Center for Wildlife Information Web site at http://www.centerforwildlifeinformation.org/.

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7 FORMS

REGISTRATION: Every participant must complete and submit the following forms

Participant Form - send PDF copy via email to blueprint4men@gmail.com

Release Form – send PDF copy via email to blueprint4men@gmail.com

Medical Form – send PDF copy to blueprint4men@gmail.com COST: Donation of $100 – make donation at www.blueprintformen.org

SIGN-UP: July 16, 2017 Deadline

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Expedition Participant Profile

Personal Information

Name_________________________________________________________________________________________ Address_______________________________________________________________________________________ Cell Phone _________________________________ Email _____________________________________________ Emergency Contact______________________________________________________________________________ Name Relationship Phone Backpacking and Climbing Experience.

On a scale of 1-5 (5 being best) how would you rate your fitness level? On a scale of 1-5 how would you rate your mountaineering (backpacking/climbing) experience? Describe your longest backpack trip. List the 3 most significant mountains you have climbed, starting with the most recent. (Include name of mountain, altitude, route, and date of each climb)

1) _________________________________________________________________________

2) _________________________________________________________________________

3) _________________________________________________________________________

Describe your outdoor skills and experience.

Describe the most extreme weather situation you have experienced in a remote setting.

What strengths do you feel you will bring to our group?

What concerns, if any, do you have concerning the physical demands of this trip?

Do you have any medical conditions that could compromise your personal or group success?

Do you have all the required equipment for this expedition? (refer to the gear list) Yes No

If no, what equipment do you need to obtain or rent?

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BLUEPRINT FOR MEN, INC Release Form

Participant Name: ______________________________________________________________________ Date of Activity: ____________________________ to_______________________________, 20 _______ Please read Release Form Carefully I am aware that during my participation in Blueprint for Men sponsored adventure activities, certain risks and dangers may occur. These include, but are not limited to: the hazards of being in a wilderness or natural area, on a physical fitness course (i.e. increased heart rate, sudden pulse rate increase, general heart risk [especially for those with past heart conditions], and death), the forces of nature, and other dangers inherent in being in or near a pool, lake, river and other recreational areas. In consideration of my voluntary election to engage in activities sponsored by Blueprint for Men, I do hereby assume all risks and to the fullest extent permitted by law do hereby agree to defend and hold harmless Blueprint for Men, their representatives, officers, employees, agents, successors, or beneficiaries from and against any and all personal injury, causes of action, losses, cost, liability, actions, debts, claims, damages, expenses, and demands of every kind and nature whatsoever, including attorney fees and court costs, which I now have or which may arise from or in connection with my presence or participation in any activities arranged for me except for gross negligence or willful acts of Blueprint for Men, its employees, agents or contractors. Further, I agree to indemnify Blueprint for Men for any causes of action, losses, cost, attorney fees, liability, actions, debts, claims, damages, expenses, and demands of every kind and nature whatsoever which I now have or which may arise from or in connection with my presence or participation in any activities arranged for me except for losses caused by gross negligence or willful acts of Blueprint for Men, its employees, agents or contractors. This agreement shall be binding upon me, my heirs, executors and administrators. I have been informed of the risks of participating in any and all activities and my participation in these activities is completely voluntary and I assume all risks associated therewith. By signing below I agree to allow Blueprint for Men to use any pictures or video footage of this program for its promotional purposes. SIGNED, this _______________day of_____________________________________, 20_____________ (Minors [anyone under the age of 18] must have their parent or guardian sign on their behalf.) NAME: ________________________________SIGNATURE: ____________________________________

(Please print full name) (If minor, signature of parent or guardian)

COMPLETE HEALTH STATEMENT FORM ON REVERSE SIDE>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

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BLUEPRINT FOR MEN HEALTH STATEMENT FORM The proposed activity provided by Blueprint for Men requires participation in physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart related or other diseases. Therefore, all participants must be free of medical or physical conditions which might create undue risks to themselves or any others in the group who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in this experience, you should consult with a physician. (NOTE: If you have had any heart related problems you will need to have a release form from a physician in order to participate in the program.) Name: ________________________________________________________________________________________ Address: ______________________________________________________________________________________ Email: __________________________________________________ Phone: _____________________________ Date of Birth: _______________________ Age: __________ Gender: __________________________ Emergency Contact Person: __________________________________________ Relationship: _________________ Home Address: _________________________________________________________________________________ Email: ___________________________________________________ Phone: _____________________________ HEALTH HISTORY (circle appropriate response) Current General Health Condition: Excellent Good Fair Poor Have you had or do you currently have any heart problems? Yes No Do you frequently suffer from pains in your chest? Yes No Do you often feel faint or have spells of dizziness? Yes No Has a doctor ever told you that you have high blood pressure? Yes No Do you have arthritis, joint or back problems that are aggravated by exercise? Yes No Have you had any operations or serious injuries? Yes No Do you have any physical disabilities or chronic recurring illness? Yes No Do you have Epilepsy? Yes No Do you have Diabetes? Yes No Are you allergic to any medication, insects or pollen? Yes No Are you currently sick and/or using medication? Yes No Do you have any prescribed meal plan or dietary restrictions? Yes No Are there any activities to be limited/discouraged by physician’s advice? Yes No Please describe any “yes” answers above: ___________________________________________________________ _____________________________________________________________________________________________ Do you carry health insurance? ____ Yes ____ No Carrier: ___________________________________________ Policy ______________________________________ REPRESENTATION AND EMERGENCY AUTHORIZATION This health history is correct so far as I know, and I believe that my health is satisfactory to participate in adventure activities. I hereby give permission to the medical personnel selected by Blueprint for Men to order injection and/or anesthesia and/or surgery for me. Such authorization for emergency treatment shall also include but is not limited to, charges incurred for the providing of aid and arranging evacuation if Blueprint for Men or its agents determine that such evacuation is necessary and desirable. I further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge any restrictions placed on my activities. Signature of Participant ___________________________________________ Date_________________________ Signature of Witness _____________________________________________ Date ________________________