Outdoor Education Participant Forms
Participant's Information
School Name: *
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Participant's Last Name: *
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Participant's First Name: *
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Participant's Middle Initial
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Gender: *
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Home Address: *
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City: *
Your answer
State: *
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Zip Code: *
Your answer
Age at Camp:
Your answer
Birth Date: *
MM
/
DD
/
YYYY
1st Emergency Contact Information
Name: *
Your answer
Daytime Phone Number: *
Your answer
Nighttime Phone Number:
Your answer
2nd Emergency Contact Information
Name: *
Your answer
Daytime Phone Number: *
Your answer
Nighttime Phone Number:
Your answer
If Emergency Contacts cannot be reached, notify...
Name: *
Your answer
Relationship to the Participant: *
Your answer
Phone Number: *
Your answer
Participant's Health Information:
Allergies: *
Required
Please describe below what the participant is allergic to and the reaction seen: *
Please type "N/A" if you have selected "No known allergies" above.
Your answer
Diet, Nutrition: *
Required
Please describe any special dietary needs/restrictions below: *
Please type "N/A" if you have selected "Participant eats a regular diet" above.
Your answer
Does the participant have any health concerns that may affect their ability to participate in the program and activities? *
Please describe if you have selected "Yes" above: *
Please type "N/A" if you have selected "No" above.
Your answer
Medication
Please list the name, dosage, times given, reason for taking any medications (prescribed or over the counter): *
Please type "N/A" if the participant does not take medication on a regular basis:
Your answer
Health Insurance
Insurance Company: *
Your answer
ID #: *
Your answer
Group #: *
Your answer
Insurance Co. Phone #: *
Your answer
Insurance Coverage Subscriber Name (Policy Holder): *
Your answer
DOB Policy Holder: *
Your answer
Company address for Claims: *
Your answer
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