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Participant

Participant Information
Please enter information about the person who will be participating in the program.


Only if different from first name


Use a format such as 05/07/2008

The date of birth you have entered is formatted incorrectly. Please try again using a fully formatted date (for example, 04/05/2008).






Participant Contact Information



Participant Address




Parent/Guardian 1

Parent/Guardian 1 Information
Please enter information about the first parent/guardian for the participant




Parent/Guardian 1 Contact Information




Parent/Guardian 2

Parent/Guardian 2 Information
Please enter information about the second parent/guardian for the participant





Parent/Guardian 2 Contact Information




Emergency Contact

Emergency Contact Information
Please enter information for an emergency contact
Be sure to add someone OTHER THAN the parent/guardian(s) already entered on the form!





Please choose an emergency contact that is different from any parent/guardians that have already been entered.



Participant Medical Information

Medical Overview



Blood Pressure

Use a format such as 120/80. Blood pressure may be taken with apparatus at a local grocery or drug store.

Within 1 year of course start
Swimming

Immunization Note:
We recommend that all of our students have a current tetanus immunization (within 10 years).

Past and Present Medical Conditions




Please provide details of any selected condition(s) in the space below. Include the following:
  • Specific symptoms and how often they occur/how long they last
  • How you care for symptoms/condition
  • Date of last occurrence
  • Any restrictions related to the condition

COVID-19 Declaration



You may be asked to submit proof of a negative viral test and/or a letter from a healthcare provider stating the participant has recovered and is cleared to end isolation.

Personal History (based on the past year)







Therapist Information



Therapist Information



Prescribing Physician



Prescribing Physician



Lifestyle




Allergies / Restrictions









Medications


If psychiatric medication, please list any medications taken or changed within the past 3 months.
 NOTE: If the participant is taking prescription medications, they MUST bring them in ORIGINAL PRESCRIPTION BOTTLES with the physician’s dosage directions. If possible, bring a double supply. If there are any changes to the medications or dosages, please contact Outward Bound

Click the "Add another response" link to add more than one medication.





Hospitalizations / Emergency Room Visits


Click the "Add another response" link to add more than one hospitalization / emergency room visit.



Exercise Activity

List the participant's current physical activity. The participant will be expected to engage in rigorous physical activity during the Outward Bound experience. It is vital that they start (or continue) a physical fitness routine in preparation for the program.

Example: Soccer – 2x/week – 45 min – Moderate

If no activity, enter "None".

Click the "Add another response" link to to add more than one physical activity




Additional Information


Next Steps

YOU ARE NOT DONE AFTER CLICKING SUBMIT! There are additional forms that will appear after this screen:
  1. Photo/Email Consent Form
  2. Medical Consent Form
  3. Survey Consent Form (for minors)
  4. Liability Release Form
  5. Parent Questionnaire (for minors)
  6. Student Questionnaire

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