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: *
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Height: *
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Weight: *
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1. Do you wear glasses or contact lenses?
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Hearing Aid?*
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2. Do you have asthma?*
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If so, please list medication (if any):
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3. Do you have a heart condition?*
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If so, please describe your limitation, medications (if any) and history:
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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:
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5. Allergies to any medications, foods, insects, plants, etc. - List below. Please describe your reaction (if you know them) to any of the above.
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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.)
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7. Describe your current physical exercise activity. Include frequency, duration and intensity.
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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.
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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:
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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.
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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.
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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.): *
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