WINDWALKER RANCH
PO BOX 105 HUSUM, WA 98623
55 LOWER SPRING CREEK ROAD
kim@windwalkerranch.org
509-637-4181
Participant’s Application and Health History
GENERAL INFORMATION
Participant______________________________________________________
Height_________ Weight__________ Gender M F
Date of Birth________________AGE_________________
Address_________________________________________________________
City______________________________________State_____ZIP__________
Email___________________________________________________________
Phone__________________________
Alternative #’s___________________
Employer/School_________________________________________________
Phone__________________________
Address_________________________________________________________
Parent/Legal Guardian____________________________________________
Phone #’s_______________________
Address(if different from above)____________________________________
________________________________________________________________
PO BOX 105 HUSUM, WA 98623
55 LOWER SPRING CREEK ROAD
kim@windwalkerranch.org
509-637-4181
Participant’s Application and Health History
GENERAL INFORMATION
Participant______________________________________________________
Height_________ Weight__________ Gender M F
Date of Birth________________AGE_________________
Address_________________________________________________________
City______________________________________State_____ZIP__________
Email___________________________________________________________
Phone__________________________
Alternative #’s___________________
Employer/School_________________________________________________
Phone__________________________
Address_________________________________________________________
Parent/Legal Guardian____________________________________________
Phone #’s_______________________
Address(if different from above)____________________________________
________________________________________________________________
