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TODAY'S DATE:September 29, 2020

Release & Waivers: REQUIRED SIGNATURES

Please make your signature here; at the end of the document, you will be asked to apply your electronic signature which will confirm that the medical information you are about to complete is correct.

If your child is a participant and you are a parent/guardian completing this form, please click on the "Minor" button and answer all questions on behalf of your child:

Please select who will be participating...
AdultMinor
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First Participant Name

First Name*

Last Name*
First Participant Date of Birth*
First Participant Information
Please choose the program you are attending:*
First Participant Signature*
Participant Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
EMERGENCY CONTACT INFORMATION:

Name: *

Relationship: *

Home Phone: *

Work/Other Phone:

Optional Alternate contact:

Relationship:

Home Phone:

Work/Other Phone:
INSURANCE INFORMATION:

 Each person is responsible for medical expenses.  Sickness and accident insurance is recommended, but not required.  Please indicate if you do NOT carry insurance.


Name of Health Insurance Carrier:
I do NOT carry health insurance.

Policy Number:

Group Plan:

Phone:
Does insurance company require pre-authorization?
Are you covered by any hospitalization care policy?

Personal/Family Physician:

Phone:
Medical Information

If you have any personal medical conditions or problems that Vermont Wilderness School should be aware of, it is your responsibility to acquaint us with the existing condition both in this form, and during the program. If any of the answers to the following questions change (other than medically insignificant changes) either between the time of completing the form and the first day of your program, or during the course of your program, it is your responsibility to confirm in writing that the Vermont Wilderness School has received the updated information. The information will be held in confidence and used only to render proper assistance should the need arise.  You should know that it is possible for participants with a variety of medical/ psychological difficulties to successfully complete our programs, but we must be aware of these conditions for our benefit and your safety.  Failure to disclose such information could result in serious harm to you and your fellow students.

If your child is a participant and you are a parent/guardian completing this form, please answer on behalf of your child:


Gender: *

Height: *

Weight: *
1. Do you wear glasses or contact lenses?
Hearing Aid?*
2. Do you have asthma?*

If so, please list medication (if any):
3. Do you have a heart condition?*

If so, please describe your limitation, medications (if any) and history:

4. Do you have any physical disabilities or limitations that could become a problem on this program? If so, please describe disability, limitation, and history:

5. Allergies to any medications, foods, insects, plants, etc. - List below. Please describe your reaction (if you know them) to any of the above.

6. Please list any medications that you take, the condition/s for which they are prescribed, the doses and schedule, and any known drug interactions. Do you experience any side effects? (In order to administer prescription medications to a child, Vermont Wilderness School requires the original labeled bottle or written directions from a doctor.)

7. Describe your current physical exercise activity. Include frequency, duration and intensity.
8. Please check all that apply:
Seizure within past year
Medical equipment needed
Family history of heart attack
Hospitalization within past 2 years
Emergency room visit within past year
Neck, back, shoulder, knee, ankle pain or injury
Have EVER sustained head trauma or had a concussion
Have NEVER been stung by a yellow jacket, bee, or wasp
Smoke, drink alcohol, illicit drug user, or other addictive habits.
Other medical issues, illnesses or symptoms

Give details on any question for which you checked "yes". Include symptoms and/or any restrictions.

9.  If you check any of the following items, we strongly suggest that you consult with a health care professional to determine whether your health status is sufficient for you to participate in the program:

High blood pressure (or currently being treated)
Heart murmur
Heart issues (Current or prior heart disease, irregular heart beat, history of heart attack)
Chronic, on-going disease such as diabetes, seizure disorder, bleeding disorder
Chest pain/pressure, heart palpitations, frequent unexplained or heart-related dizziness or fainting, sweats or weak spells.
Age 45 or more with family history of heart attack and/or severely overweight

Describe in detail any of the above for which you checked:

10. Any mental, emotional or psychological issues we should be aware of at this time? All information is kept confidential and is meant to provide a supportive and safe atmosphere for all involved in the program.

11. First Aid supplies include bandages, gauze pads, tape, Hydrogen Peroxide, Neosporin, Benadryl. We also have Rescue Remedy, some essential oils (therapeutic grade), herbal salves, Arnica tabs and gel, etc.; things we use for ourselves. Please indicate if there is anything in this list that you definitely do not want us to use in the unlikely event that an accident occurs. If you leave this section blank, we will follow basic first aid protocol.

12: Date of your last tetanus booster (Note: tetanus boosters are generally recommended first at age 5, and then every ten years thereafter. It is recommended that children who get deep, dirty wounds or puncture wounds more than five years after their last booster receive another booster promptly.): *
Medical Release

The information provided on my Confidential Medical record and Participant Questionnaire is a complete and accurate statement of the physical and psychological factors, which may affect my or my child's participation in a Vermont Wilderness School program. I realize that failure to disclose such information could result in serious harm to myself/my child/fellow students.  I agree to indemnify and hold Vermont Wilderness School harmless if all relevant information is not disclosed.  I further understand that if any of my or my child's medical information changes either between the time of completing the form and the first day of my or my child's program, or during the course of my or my child's program, it is my responsibility to notify the Vermont Wilderness School in writing.

I hereby give consent for Vermont Wilderness School to administer routine medical care, Standard First Aid, or Wilderness First Aid for myself and/or my child if it becomes necessary as a result of participation in a Vermont Wilderness School program. In case of medical emergency I hereby give consent to the Vermont Wilderness School and any physician they select to secure proper treatment. I understand that every effort will be made to first contact the participant's designated emergency contact person, responsible parent, or guardian. I further understand that if I do not have medical insurance that covers all costs, I will be responsible for such medical costs. I understand that my printed name in the box below serves as my electronic signature and gives consent for my or my child's emergency hospitalization if it becomes necessary as a result of participation in this program.

I affirm that my agreement, consent, acknowledgement, and understanding to or of any and all the above statements may be applied to all Vermont Wilderness School programs, workshops, events, and gatherings that I or my child participate in for the 12 months following the first day of the program I selected earlier in this form.

Release, Indemnification, and waiver form

(This is a release--please read it carefully:)

At Vermont Wilderness School, the safety of each student is our highest priority.We take all reasonable precautions to ensure you and/or your child's physical and emotional safety and to provide a quality experience that focuses on fun, safety and character development. However, as in any other experience, we cannot eliminate all risk from our programs.

The risks include, but are not limited to insect and animal bites and stings, forces of nature such as but not limited to lightning, illness, disease, and unexpected extreme weather conditions, and any hazard present in the wilderness, such as but not limited to low lying branches, sharp objects, and slippery surfaces.

I, the undersigned, hereby acknowledge that I have been advised and fully understand that certain elements of danger are inherent in the activities sponsored by the Vermont Wilderness School which are beyond the control of the instructors, agents, officers, students, and employees of the Vermont Wilderness School, and that participation in any program activities may entail unavoidable risk of personal injury, death, and loss or damage to property. 

Knowing there are risks, I hereby assume all risks of injury, illness and disease, and death to me or my child and loss of, or damage to property arising out of my or my child's participation in such activity and I agree to indemnify, hold harmless the Vermont Wilderness School, its officers, instructors, agents and employees from and against all claims arising from any occurrence causing damage or injury to myself or my child or to any party participating in said event or any third parties injured as a result of my or my child's actions.  I further agree to repair or reimburse the Vermont Wilderness school for any and all damages that me or my child causes to Vermont Wilderness School property or the property at which a specific activity is held.

I have read and understand the terms and conditions of this Release, Indemnification, and Waiver and I agree to subscribe to them.

I affirm that my agreement, consent, acknowledgement, and understanding to or of any and all the above statements may be applied to all Vermont Wilderness School programs, workshops, events, and gatherings that I or my child participate in for the 12 months following the first day of the program I selected in this form.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please choose the program you are attending:*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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