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Welcome to Cathleen Stone Island Outward Bound! This application will take around 10 minutes to complete. If needed, you can use the option to save and continue later.









Participant

Participant Information
Please enter information about the person who will be participating in the program.


Only if different from first name


Use a format such as 05/07/2008

The date of birth you have entered is formatted incorrectly. Please try again using a fully formatted date (for example, 04/05/2008).







Participant Contact Information



Participant Address




Parent/Guardian 1

This page shows only for participants who are under 21
Parent/Guardian 1 Information
Please enter information about the first parent/guardian for the participant




Parent/Guardian 1 Contact Information




Parent/Guardian 2

Parent/Guardian 2 Information
Please enter information about the second parent/guardian for the participant





Parent/Guardian 2 Contact Information




Emergency Contact

Emergency Contact Information
Please enter information for an emergency contact
Be sure to add someone OTHER THAN the parent/guardian(s) already entered on the form!





Please choose an emergency contact that is different from any parent/guardians that have already been entered.



Participant Medical Information

Medical Overview



Blood Pressure

Use a format such as 120/80. Blood pressure may be taken with apparatus at a local grocery or drug store.

Within 1 year of course start
Immunization Note:
We recommend that all of our students have a current tetanus immunization (within 10 years).

Past and Present Medical Conditions

This page shows only for minors





Past and Present Medical Conditions

This page shows only for adults





The options below show only for overnight programs



Personal History (based on the past year)

This page shows only for minors on an overnight program 






Therapist Information



Therapist Information



Prescribing Physician



Prescribing Physician



Allergies / Restrictions









Medications

This page shows only for minors on an overnight program 

If psychiatric medication, please list any medications taken or changed within the past 3 months.
 NOTE: If the participant is taking prescription medications, they MUST bring them in ORIGINAL PRESCRIPTION BOTTLES with the physician’s dosage directions. If possible, bring a double supply. If there are any changes to the medications or dosages, please contact Outward Bound

Click the "Add another response" link to add more than one medication.





Exercise Activity

This page shows only for overnight programs
List the participant's current physical activity. The participant will be expected to engage in rigorous physical activity during the Outward Bound experience. It is vital that they start (or continue) a physical fitness routine in preparation for the program!

If no activity, enter "None".

Click the "Add another response" link to to add more than one physical activity




Additional Information


Next Steps

YOU ARE NOT DONE AFTER CLICKING SUBMIT! There are additional forms that will appear after this screen:
  1. Medical Consent Form
  2. Liability Release Form
  3. Survey Consent Form (for minors)
YOU ARE NOT DONE AFTER CLICKING SUBMIT! There are additional forms that will appear after this screen:
  1. Medical Consent Form
  2. Liability Release Form
  3. Survey Consent Form (for minors)

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