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Course Information

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Good news! You have already completed and signed the medical record for this application. This online form cannot be submitted a second time. If you need to update the medical information for this application, please contact your Course Advisor. 
Let's get started with your application!  You will need about 20-30 minutes to complete and can save your progress and resume at a later date.

Information will be kept confidential and will be used for the evaluation of your health and readiness to participate on your Outward Bound course.  























Unfortunately, the deadline for applying for this course has passed. Please reach out to studentservices@pobs.org to discuss options.


Applicant Information


First, we'll collect some information about the applicant.




Jr, Sr, III, etc.



The Student ID Number issued by your school

MM/DD/YYYY




Understanding an applicant's gender identity helps our staff provide the best support, both in preparation for course and on course. Options are included for applicants who do not identify exclusively as male or female.






















Providing a mobile phone enables you to opt in to receive text message notifications regarding the status of your Outward Bound application.



Veterans Course Details


Outward Bound Veterans courses are open to active duty servicemembers and veterans of all conflicts who have deployed or have been stationed overseas as a part of their service.


Grieving Teens Course



This is important for us to know prior to interviewing the applicant.

MM/DD/YYYY


This demographic information is being collected on behalf of the NY Life Foundation and will not be associated with your name or used for any other purpose

Parent/Guardian Information (Required If Applicant is Under the Age of 18)







Jr, Sr, III, etc.





















Secondary Parent/Guardian Information







Jr, Sr, III, etc.



This parent/guardian will be the primary point of contact during the enrollment process. If you would like either the applicant or the previous parent to be the primary contact, please change your response on one of the previous pages.

















Emergency Contact (Other than a parent or guardian if the applicant is under 18)







Applicant Medical History: Past & Present

Next, we'll collect medical information about the applicant. We recognize it may feel like we are asking a lot of questions.  Please take the time to read each question completely. 

It is important for us to get accurate medical information in order to help prepare and set participants up for success as well as for our staff to provide the best possible support during the course.

Your responses will be kept confidential and will help determine any additional forms we may need you to complete.  




Knowing an applicant's sex helps our staff provide the best support, both in preparation for course and on course. The intersex option is available for applicants born with a mix of male and female biological traits.





Do any of the following conditions apply to the applicant?
If yes, please use the space provided to provide additional information, including:
  • Specific symptoms that are occurring
  • How often those symptoms or conditions occur
  • How long each symptom or condition usually lasts
  • How you care for each symptom or condition
  • Date of last occurrence of each condition
  • Any restrictions

Please indicate which conditions apply. 











Please indicate which conditions apply. 







Please indicate which conditions apply. 







Please indicate which conditions apply.













Please indicate which conditions apply. 















Please indicate which conditions apply.









Please indicate which conditions apply. 






Please indicate which conditions apply.






















Please also respond to the following questions. We will ask for more details in the following sections.





Allergies

Please list all of the applicant's allergies to medications, foods, insect bites/stings, or other substances. Click Add Another Allergy to add additional allergies.




Applicant Mental Health History: Within The Past Year

Do any of the following apply to the applicant within the last year? If yes, please describe.




































Medications

Please list all prescription and over-the-counter medications taken by the applicant including vitamins, herbal or natural supplements and inhalers. If the applicant is taking psychiatric medication, please list any medications taken or changed within the past 3 months.

If the applicant is taking prescription medications, they must bring them in ORIGINAL PRESCRIPTION BOTTLES with the physician's dosage instructions.




MM/DD/YYYY



MM/DD/YYYY

Hospitalizations/Emergencies

Please list any applicant hospital, psychiatric, or urgent care visits within the past year. Click Add Another Visit to add additional visits.


MM/DD/YYYY


Blood Pressure (Optional)

Please tell us about the applicant's most recent blood pressure reading (must be within one year of course start date). Blood pressure may be taken with apparatus at a local grocery or drug store.

Blood pressure readings are usually reflected as a systolic value (top number) over a diastolic value (bottom number). For example, if your blood pressure is 120/80, 120 is the systolic value and 80 is the diastolic value.

MM/DD/YYYY


Additional Questions





Exercise Activity




Current Physical Activity
List the applicant's physical activity, if any. The applicant will be expected to engage in rigorous physical activity during their Outward Bound experience. Click Add Another Activity to add additional physical activities.




Additional Information


Applicant Participation, Authorization and Consent for Treatment


Your Enrollment Form has 2 Parts:
1.  Medical Form
2. Liability Release

After submitting this Medical Form, please wait a moment for your Liability Release to load.

Over the years, many students with a variety of medical and psychological difficulties have successfully completed our programs, but we must be aware of these conditions. Failure to disclose such information could result in serious harm to you (or your child) and fellow students. If you (or your child) arrive at the program start with a preexisting medical, behavioral or psychological condition which is not indicated on your medical form and you are subsequently unable to participate fully or are forced to leave the program because of that condition, you may be charged an evacuation fee and will not receive a refund of tuition.

SIGNATURE REQUIRED:
I understand the above paragraph and agree to its terms. Consent is hereby given for the applicant to attend an OUTWARD BOUND program and permission is given for any emergency anesthesia, operation, hospitalization or other treatment (whether for an emergency or not) which might become necessary. I agree to be responsible for any and all costs associated with such treatment, including the costs of evacuation, if any. All information will be kept confidential except that information may be disclosed to any medical or other provider as needed for my (or my child’s) care. If Outward Bound arranges for treatment for me (or my child) by a medical provider, I authorize that medical provider to release information about me (or my child), and my (or my child’s) condition and treatment to Outward Bound. I understand that I (or my child) may be in remote areas, several hours or days away from any medical facility or where communication, transportation, or evacuation is subject to delay.

Please click Proceed to E-Signature to e-sign for consent. 

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