Participant Application

ALL applications are subject to final approval by BOEC Program Staff. Completing this application DOES NOT guarantee you a spot in a program. Please read our enrollment guidelines for winter or summer before applying to ensure participation is right for you. If you have further questions regarding eligibility, please call our office (970)-453-6422.

Program Interest

Is the applicant a returning participant to BOEC?

YesNo

To the best of your recollection what was the date of the last event the applicant attended?

What types of programs is this applicant interested in?

Winter-based programs (adaptive ski & snowboard lessons)Summer-based programsBoth summer and winter-based programs

Please briefly describe the program the applicant wishes to attend

Applicant Information

First Name

Middle Name

Last Name

Birthdate

Phone

Email

(Primary contact for all BOEC programming)

Height (ft.)

(in.)

Weight (lbs)

Gender

Prefer to self-identify

Ethnicity

Please self-identify here

Primary Address

City

State/Province

Zip/Postal Code

Please add Primary Emergency Contact Information (Parent, Guardian, Caregiver, etc...)

First Name

Last Name

Phone

Email

Relationship

Please add the contact information for any additional contacts for this applicant. (Please, add all that apply)

First Name

Last Name

Phone

Email

Relationship

Medical Insurance

Please note: We recommend that all BOEC students be covered by personal health insurance. If medical care for injury, pre-existing condition or any other reason is required during a BOEC course, the student’s personal health insurance will be primary.

Is applicant covered by Medical Care Policy?

YesNo

Medical Insurance Policy (carrier and type)

Policy Number:

Armed Forces

Is the applicant Active Duty Military or a veteran of the US Armed Forces?

YesNo

Is the applicant related to a member of the armed forces who will also be participating?

YesNo

Status

Branch

Rank

Years of Active Duty

Separation Date

Does the applicant have combat related injuries?

YesNo

Date of Onset

Medical History

Has the applicant received the COVID-19 Vaccine?

YesNo

Within the last year has the applicant had any any operations, hospitalizations or serious injuries?

YesNo

If yes, please list and explain.

Seizures

Is the applicant subject to seizures?

YesNo

Pease list any type of seizures the applicant experiences and the frequency.

Date of last seizure?

Are seizures controlled by medication?

YesNo

Please describe what we may expect of a typical seizure? You may include warning signs, duration, any specific care required, and recovery time.

Medications

Does the applicant take any medications including any prescription or over-the-counter medications?

YesNo

Please list any medications and what they are for.

Experience/Goals

What does the applicant like to do for fun?

Please list any goals or opportunities you would like to work towards? (These can include social, physical, or recreational goals)

Please describe any outdoor recreational experiences the applicant may have (camping, hiking, water sports, rock climbing, etc...)

Files and Attachments

Please upload any documents such as medication records, vaccine cards, etc...

Newsletter

Check to stay up to date on BOEC via the Monthly Inspirations E-Newsletter.

Comments, Questions, or Concerns

Additional comments, questions, or concerns

Application Acknowledgement

The Breckenridge Outdoor Education Center is committed to offering quality outdoor education to people of all abilities. All prospective students are required to fill out this student application. The above information assists the BOEC in maintaining a risk managed environment. Not completing this form as accurately and truthfully as possible, providing misinformation, or leaving out certain information could result in an injury or may compound the severity of an injury. This information will be kept confidential. We reserve the right to screen all students and may request that you provide a personal caregiver to join the program.

I have read the above application acknowledgement and agree to its conditions.

I understand that the winter application process must still be completed by calling the BOEC ski program office at (970)453-5633 to confirm my application was received

I understand

Upon submission, you will be redirected to complete our Release of Liability and Statement of Informed Consent documents. These must be signed on the applicant's behalf in order to participate in a BOEC program.

None	ADD/ADHD	ALS	Autism Spectrum Disorder
Bereaved	Bipolar Disorder	Cancer	Cerebral Palsy
Cleft Lip/Palate	Cognitive Impairment	Conduct Disorder	Down Syndrome
General Anxiety Disorder	Hearing Impairment	Hemophilia	Learning Disability
Major Depressive Disorder	Multiple Sclerosis	Muscular Dystrophy	Neurocognitive Disorder (Dementia)
Panic Disorder	Parkinson's Disease	Personality Disorder	Physical Injury (amputation)
Prader-Willi Syndrome	PTSD	Schizophrenia	Speech Impairment
Spina Bifida	Spinal Cord Injury	Stroke	Substance Abuse
Brain Injury/Traumatic Brain Injury	Visual Impairment	William's Syndrome	Other (write in)

None	Vegetarian
Vegan	Gluten-free
Kosher	Halal
Lactose-intolerant	Sugar-free
Thick-it	Portion-control
Other

None	Visual Impairment
Hearing Impairment	Asthma or any other respiratory conditions
Altitude sickness	High blood pressure
Heart conditions including (heart disease, irregular heartbeat, other)?	Diabetes, Thyroid, or other Endocrine Conditions?
Chronic skin problems including rash, infection or poor circulation?	Reaction to extreme temperatures including frostbite, sunburn or heatstroke?
Bone or joint issues including broken bones, arthritis, joint dislocations, serious sprains	Other

Crutches	Cane/Walker
Prosthetic	Power Chair
Manual Chair	Other

Verbally	Non Verbally
Yes/No Questions	Sign Language
Devices	Gestures/Body Language
Other