Custom Course Enrollment Form

Page 1

Please have your medical history and background information ready!

This form will take about 10-15 minutes to complete.

PASSPORT & VISA

All persons arriving in Costa Rica are required to show:

A roundtrip/outbound ticket with a departing flight no more than 90 days after your arrival.
A valid passport with an expiration date 6 months after your date of departure. (Departing Costa Rica June 30, 2023 - passport must be valid until at least December 31, 2023)

European, British, Canadian, and United States citizens are eligible for a 90 day tourist visa upon entry to Costa Rica. This is a free renewable Visa and will be issued when you arrive in Costa Rica. If you have any questions about visas, please visit your country's embassy website for Visa requirements, restrictions, and prices.

Does the participant have a valid passport?

YesNoIf you answered no, as soon as you receive your new passport please send our team a clear photo or scanned copy to custom@outwardboundcr.org.

Passport Country

Passport Number

Passport Expiration Date (MM/DD/YYYY)

COVID-19 VACCINATION STATUS

We encourage everyone to be fully vaccinated before the start of our programs (all of our staff are fully vaccinated!), but not required to at this time. Be aware that vaccine requirements may change in the future per gov't requirements OR per collaboration with your group leader.

Please indicate your vaccination status below

I am fully vaccinatedI will be fully vaccinated at least 14 days prior to the start of programI will not be getting vaccinated

REQUIRED: Emergency Contact Information

Primary Emergency Contact

This MUST be an immediate family member—preferably a parent/guardian.

Full Name

Relationship

Email

Mobile Phone

Home Phone

Work Phone

Street

City/Town

State/Region

Zip/Post Code

Country

Secondary Emergency Contact

This MUST be an immediate family member—preferably a parent/guardian.

Full Name

Relationship

Email

Mobile Phone

Home Phone

Work Phone

Street

City/Town

State/Region

Zip/Post Code

Country

Tertiary Emergency Contact

Full Name

Relationship

Email

Mobile Phone

Home Phone

Work Phone

Family Relation Notes

Are there any family relations we should be aware of if we need to be in touch with your emergency contact(s)? If yes, please elaborate.

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Code of Conduct

I will:

Respect the places and the people with whom I come in contact on my course
Not bring, purchase or use alcohol, tobacco products or illegal drugs during any portion of course
Not engage in any conversation topics or actions that knowingly intimidate, exclude, or alienate other members of my group
Be responsible for my personal belongings and equipment and will not hold OBCR or my instructors responsible for their loss or damage due to my negligence or neglect
Treat all equipment provided by OBCR with care
Refrain from use of harmful and abusive language while on course
Be an active participant on my course and will do my best to engage in new activities, work as part of a group and follow instructions
Obey all policies and safety guidelines established by my instructors
Not engage in or display any exclusive relationships; no kissing; no romantic interest, no engaging in any sexual or romantic activity, and not exclusively spending time with another person. This applies equally to same sex and opposite sex individuals
Never display any aggressive behavior toward anyone in my group or my instructors

I acknowledge that I understand that my attitude and behavior are critical to the success of this course. For the good of this course, myself, and my fellow group members, I agree to abide by the Code of Conduct as described above. I understand that if I break one of these rules, I am subject to termination of course without refund.

I Agree

Terms of Service

Please read and acknowledge our Terms of Service.
I have read and understand the Terms of Service regarding the release of liability, assumption of risk, and immunization waiver and agree to it of my own free will and without reservation.

Yes

Media Release

I grant to Outward Bound Costa Rica (OBCR) the right to use my image and name in all forms and media including social media, marketing materials and additional assets. I waive the right to approve versions of my image used or the written copy that may used in connection with the images.

YesNo

Signatures

I certify the information I provided on this form is true and correct. I agree to Outward Bound Costa Rica's Terms of Service and Code of Conduct and acknowledge my accordance by signing and dating the Enrollment Form electronically.

I Agree

Participant's Name

Participant's Electronic Signature

Are you under 18?

Yes

No

Parent or Guardian's Name

Parent or Guardian's Electronic Signature

Medication 1 Medication 1 Name Dosage Side Effects Special Requirements Reason for Medication	Medication 2 Medication 2 Name Dosage Side Effects Special Requirements Reason for Medication
Medication 3 Medication 3 Name Dosage Side Effects Special Requirements Reason for Medication	Medication 4 Medication 4 Name Dosage Side Effects Special Requirements Reason for Medication

Anxiety	Depression
Panic Attacks	Additional Mental Health Symptoms/Diagnoses
Learning Disability	ADD/ADHD
Autism	Kidney Problems
Thyroid Problems	Endocrine Problems
Hearing Impairment	Vision Impairment
Dental Problems	Intestinal Problems
Stomach Ulcers	Skin Problems
Head Injury	Broken Bones
Neck Problems	Back Problems
Arm Problems	Shoulder Problems
Knee Problems	Ankle Problems
Leg Problems	Foot Problems
Circulation Problems	Bleeding Disorder
Anemia	Jaundice
Hypoglycemia	Diabetes
High Blood Pressure	Heart Disease
Heart Murmur	Heart Palpitations
Irregular Heartbeat	Heartburn
Chest Pain	Asthma
Frequent Shortness of Breath	Frequent Dizziness
Sensitive to High Elevations	Motion Sickness
Intolerant to Cold Temps	Intolerance to Warm Temps
Heatstroke	Tuberculosis or Positive TB test
Active Hepatitis	History of Hepatitis
Use of Medical Equipment	Seizure(s)
Epilepsy	Cancer
Muscle Cramps	Menstrual Problems and/or PMS
Bladder Infection	Difficulty Urinating
Unexplained Sweating	Obesity
Currently Pregnant	Active Bedwetting
Anorexia Nervosa	Bulimia
Headaches	Frost Bite
Any Other Conditions