Wilderness Club: Student Information Form
Complete the documents that need to be signed then return to fill out the other parts of this form. All of this can be done on a mobile device.
Except where indicated, these may only be completed by a parent or legal guardian.
PARTICIPANT AGREEMENT & MEDIA RELEASE
In order for your child to participate you need to sign the Participant Agreement & Media Release using the link below.
In an emergency, if we are unable to reach you or the secondary guardian you listed, who else may we contact?
Relationship to Child
Alternate Emergency Contact Name
Relationship to child
GENERAL HEALTH & FITNESS
Does Your Child Exercise Regularly
If yes, please note the activity, how often, and how long.
Does your child have any allergies?
If yes, please list their allergies, the type of reaction they get, and their medications (if any).
Does your child currently take any medications?
If yes, please list all medications your child is taking (including non-prescription or over-the-counter medication). Also include what symptoms they demonstrate, medication dosage (how often & how much), a start date, and side effects (if any).
Has your child been hospitalized, visited the emergency room or urgent care in the last 2 years?
If yes, please list the date of the visit(s), reason for the visit(s), and length of the stay(s).
Does your child have food allergies?
If yes, please list.
Please check all that your child does NOT eat.
Please check if your child is one of the following.
Are your child’s immunizations up to date?
Please check if your child currently has or has had any of these conditions in the past. If not, check none of the above at the bottom.
Vision impairment (including glasses/contact)
High blood pressure
Irregular heart beat
Family history of heart attack
Unexplained chest pain/pressure
Frequent dizziness or fainting
Seizure in the past year
Intolerance to cold/warm temperatures
Frequent muscle cramps
Physical aids/medical equipment
Recurrent lung infections
Sleeping problems (including sleepwalking)
None of the above
If you answered yes to any of the above boxes please explain below. Include the condition and a description.
Are there any other physical conditions that may limit your child’s participation in the activities?
No, my child is capable of participating fully
Yes, I have concerns about my child’s ability to participate
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This form was created inside of Team Wilderness.