People with a variety of medical and/or psychological considerations have successfully completed VWS programs. It is vital that we have all relevant information to help us co-create a successful environment for participants. If you have any personal health or wellness considerations that Vermont Wilderness School should be aware of, it is your responsibility to inform us of the details of your situation both in this form and during the program. If any of the answers to the following questions change (other than medically insignificant changes) either between the time of completing the form and the first day of your program, or during the course of your program, it is your responsibility to confirm in writing that the Vermont Wilderness School has received the updated information. Failure to disclose such information could result in serious harm to you and your fellow students.
All information is kept confidential, is meant to provide a supportive and safe atmosphere for all involved in the program, and will be used only to render proper assistance should the need arise.
If your child is a participant and you are a parent/guardian completing this form, please answer on behalf of your child.
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Gender: *
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Height: *
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Weight: *
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1. Do you wear glasses or contact lenses?
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Hearing Aid?*
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2. Do you have asthma?*
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If so, please list medication (if any):
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3. Do you have a heart condition?*
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If so, please describe your limitation, medications (if any) and history:
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4. List any allergies you have to medications, foods, insects, plants, etc. Please describe your allergic reaction(s) (if you know) and whether or not you carry an epi-pen or other epinephrine injection device.
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5. Please list any medications that you take, the condition/s for which they are prescribed, the doses and schedule, and any known drug interactions. Do you experience any side effects? (In order to administer prescription medications to a child, Vermont Wilderness School requires the original labeled bottle or written directions from a doctor.)
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6. Describe your current physical exercise activity. Include frequency, duration and intensity.
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7. Please check all that apply: |
Seizure within past year |
Medical equipment needed |
Family history of heart attack |
Hospitalization within past 2 years |
Emergency room visit within past year |
Neck, back, shoulder, knee, ankle pain or injury |
Have EVER sustained head trauma or had a concussion |
Have NEVER been stung by a yellow jacket, bee, or wasp |
Smoke, drink alcohol, illicit drug user, or other addictive habits. |
Other medical issues, illnesses or symptoms |
Give details on any question for which you checked "yes". Include symptoms and/or any restrictions.
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8. If you check any of the following items, we strongly suggest that you consult with a health care professional to determine whether your health status is sufficient for you to participate in the program:
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High blood pressure (or currently being treated) |
Heart murmur |
Heart issues (Current or prior heart disease, irregular heart beat, history of heart attack) |
Chronic, on-going disease such as diabetes, seizure disorder, bleeding disorder |
Chest pain/pressure, heart palpitations, frequent unexplained or heart-related dizziness or fainting, sweats or weak spells. |
Age 45 or more with family history of heart attack and/or severely overweight |
Describe in detail any of the above for which you checked:
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9. Is there anything regarding physical or intellectual disability, mental/emotional/psychological challenges, or anything else pertaining to the participants' health and wellness that we should be aware of that you have not yet disclosed in this form or through the registration process?
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10. First Aid -- Please CHECK OFF ITEMS YOU DO NOT PERMIT US TO USE in the unlikely event that an accident occurs. |
Neosporin, Bacitracin, or Triple Antibiotic Ointment (generic brand) |
Xeroburn (gel for burns) |
After Bite (for insect bites) |
Hemostatic agent (to staunch severe bleeding) |
Benadryl or diphenhydramine (generic brand) for mild allergic reactions |
Rescue Remedy (homeopathic remedy for anxiety) |
Essential oils (therapeutic grade) |
Herbal salves (to heal irritated skin and small wounds) |
Arnica tabs and gel (homeopathic remedy for bruises, sprains and muscle soreness) |
11. Date of your last tetanus booster (Note: tetanus boosters are generally recommended first at age 5, and then every ten years thereafter. It is recommended that children who get deep, dirty wounds or puncture wounds more than five years after their last booster receive another booster promptly.): *
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