For which course would you like to register?":

Name:

Address:

Mother's Name::

Address (if different):

Father's name:

Address (if different):

Does your child own a pocketknife?:(Please click to check the box if the answer is yes)

Do you give your child permission to use a pocketknife?:(Please click to check the box if the answer is yes)

Emergency contact: Name, telephone number:

Child's home telephone number:

Daytime contact number:

Date this form was completed:

Doctor's name:

Doctor's telephone number:

In the event a medical emergency occurs and the Guardian or emerency contact cannot be reached do you authorize any supervising adult to seek medical attention for your child?:(Please click to check the box if the answer is yes)

Would you like to be informed of other such courses?:(Please click to check the box if the answer is yes)

Are you aware that our instructor is living on site and would welcome visits from parents, siblings and interested persons after 5 PM?:(Please click to check the box if the answer is yes)

Would you be interested in an adult survival course?:
(Please click to check the box if the answer is yes)

Would you be interested in volunteering to help us in our program? (No experience necessary):(Please click to check the box if the answer is yes)

Do you have any particular concerns or questions about our program? If so, please explain:

What would you like to see this course accomplish for your youngster:

Would you be interested in participating in a primitive survival camping trip with your youngster?:(Please click to check the box if the answer is yes)

 What is your e-mail address?:

Would you like to be kept informed, via e-mail, about our upcoming programs?:(Please click to check the box if the answer is yes)

Where did you find out about us?:

Is this child medically excused from Physical education at the present time?:(Please click to check the box if the answer is yes)

Was your child ever advised not to allow this child to participate in strenuous activites?:(Please click to check the box if the answer is yes)

Do you have any worries about this child's health or think that there may be some reason s/he shouldn't participate?  :(Please click to check the box if the answer is yes)

Have you ever initiated a lawsuit against a camp or athletic organization? :
(Please click to check the box if the answer is yes)

Ever been unconscious after an injury?:(Please click to check the box if the answer is yes)

Ever had a fracture or dislocation?:(Please click to check the box if the answer is yes)

Ever had any surgery?:(Please click to check the box if the answer is yes)

Ever contracted Lyme's Disease?:(Please click to check the box if the answer is yes)

Within the last year: (check box(es) to answer "yes")

Ever experienced frequent chest pains/ palpitations?:

Is this child on any medications which would have to be administered during the course of the day? (During the program's hours) :(Please click to check the box if the answer is yes)

Have a history of fainting with exercise?:(Please click to check the box if the answer is yes)

Have a history of undue tiredness or fatigue?:(Please click to check the box if the answer is yes)

Have a history of a family member having sudden unexplained death under the age of 40 years?:(Please click to check the box if the answer is yes)

Is this child under a physician's care now?:(Please click to check the box if the answer is yes)

Asthma:(Please click to check the box if the answer is yes)

Heart Problems:(Please click to check the box if the answer is yes)

High Blood Pressure:(Please click to check the box if the answer is yes)

Rheumatic Fever :(Please click to check the box if the answer is yes)

Kidney Trouble:(Please click to check the box if the answer is yes)

Bee Sting Allergy:(Please click to check the box if the answer is yes)

Drug or Food Allergies:(Please click to check the box if the answer is yes)

Diabetes:(Please click to check the box if the answer is yes)

Epilepsy:(Please click to check the box if the answer is yes)

Excessive bleeding:(Please click to check the box if the answer is yes)

If you answered "yes" to any of the questions, please elaborate:

Do you certify that the above information is true and accurate to the best of your knowledge, information, and belief, and do you further understand that if your child's conduct compromises the safety or learning atmosphere of the course, the instructor reserves the right to expel your child from the course without refunding your money?(Please check if the answer is yes):