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.
Child's Name *
Your answer
PARTICIPANT AGREEMENT & MEDIA RELEASE
In order for your child to participate you need to sign the Participant Agreement & Media Release using the link below.

https://na2.docusign.net/Member/PowerFormSigning.aspx?PowerFormId=296185f6-ca11-486f-96a0-902bdd27b19d&env=na2&v=2
EMERGENCY CONTACTS
In an emergency, if we are unable to reach you or the secondary guardian you listed, who else may we contact?
Name *
Your answer
Relationship to Child *
Your answer
Work Phone *
Your answer
Home Phone
Your answer
Cell Phone *
Your answer
Alternate Emergency Contact Name
Your answer
Relationship to child
Your answer
Work Phone
Your answer
Home Phone
Your answer
Cell Phone
Your answer
GENERAL HEALTH & FITNESS
Does Your Child Exercise Regularly *
If yes, please note the activity, how often, and how long.
Your answer
Does your child have any allergies? *
If yes, please list their allergies, the type of reaction they get, and their medications (if any).
Your answer
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).
Your answer
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).
Your answer
Does your child have food allergies? *
If yes, please list.
Your answer
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. *
Required
If you answered yes to any of the above boxes please explain below. Include the condition and a description.
Your answer
Are there any other physical conditions that may limit your child’s participation in the activities?
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