For participation in the summer week-long Primitive Survival Skills experience, to be completed and signed by the parent of the participant.
We offer scholarships in case of financial need, through the South Toms River Alliance.
STR RESIDENT RATE       OTHER RATE
Name: Birthdate:
Address: Phone #:
Mother's Name:
Address (if different): Phone #(if different)
Father's Name:
Address (if different) Phone #(if different)
Does your child own a pocketknife?  Y    N
Do you give permission for him/her to use a pocketknife?         Y       N
Emergency contact:
 		 Phone #
 In the event that a medical emergency occurs and the Guardian or emergency contact cannot be reached I hereby authorize any supervising adult involved to seek medical attention for my child.

______________________________________                  ________________________________
Signature                                                                                 Date
Sorry, no refunds.
 

Doctor's name________________________________________________phone #________________
Medicalconcerns_________________________________________________________________________
__________________________________________________________________________________
1. Is this child medically excused from Physical education at the present time?   Y   N
2. Were you ever advised not to allow this child to participate in strenuous activites?  Y   N
3. Do you have any worries about this child's health or think that there may be some reason s/he shouldn't participate?          Y     N
4. Is this child participating in this activity because s/he truly wants to do it?  Y    N
5. Have you ever initiated a lawsuit against a camp or athletic organization?  Y  N
6. Has s/he -
   a) Ever been unconscious after an injury?  Y  N
   b) Ever had a fracture or dislocation?  Y  N
   c) Ever had any surgery?   Y   N
   d) Ever contracted Lyme's Disease?  Y   N
   e) Within the last year, had to stay at the hospital overnight? Y  N
   f) Ever experienced frequent chest pains/ palpitations?
   g) Is on any medications which would have to be administered during the course of the day? (During the program's hours)  Y  N

7. Does s/he
     a) Have a history of fainting with exercise?   Y   N
     b) Have a history of undue tiredness, fatigue?  Y  N
     c) Have a history of a family member having sudden, unexplained death under the age of 40 years?  Y  N

8. Is this child under a physician's care now?  Y  N

9. Has this child ever had:
 
Asthma Y  N Bee Sting Allergy   Y   N
Heart Problems Y  N Drug or Food Allergies   Y   N
High Blood Pressure  Y  N Diabetes   Y  N
Rheumatic Fever  Y  N Epilepsy   Y  N
Kidney Trouble  Y  N Excessive Bleeding   Y  N
10. If you answered yes to any of the above, please explain including dates of any illness or injury.

I/We  hereby certify that the above information is true and accurate to the best of my/our knowledge, information and belief, and I further understand that if my child's conduct compromises the safety or learning atmosphere of the course, the instructor reserves the right to expel my child from the course, without recompensation.

______________________________________                     ___________________________
Signature of Parent or Guardian                                                     Date
 
 
 
Would you like to be informed of other such courses?
Y N		 Are you aware that our instructor is living on site, and would welcome visits from parents, siblings, and interested persons after 5 PM?
Y  N
Would you be interested in an adult Primitive Survival Course?   Y  N  Would you be interested in participating in a primitive survival camping trip with your child/ren?
Y  N
Would you be interested in volunteering to help us in our program? (no experience or knowledge necessary)
Y  N		 Do you own  a computer, or have an e-mail address?
if so, what is your e-mail add?:
Would you like to be kept informed about our programs via e-mail?  Y   N
Do you have any particular concerns or questions about our program? Please use the opposite empty box to explain.
What would you like to see this course accomplish for your youngster? Please use the opposite empty box to answer.