Youth Backcountry Registration Form

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Program *

Select the program(s) your child is interested in joining. (Select all that apply)

YBC-121 INTERMEDIATE: JUN 20-22 (Entering 8th -9th grade)

YBC-221 NOVICE: JUN 23-25 (Entering 6th-7th grade)

YBC-321 ADVANCED: JUN 28-JUL 1 (High School)

YBC-421 ADVANCED: JUL 17-20 (High School)

*Private Program

Required

*If your trekker is participating in a private program, please enter the program date:

Participating Child's LAST NAME *

Participating Child's FIRST NAME *

Guardian Primary Contact Email *

Please make sure to type in correctly, this will be our primary way of contacting you with important details for program.

Parent/Guardian Full Name *

Participant's Gender *

Participant's Age *

For backpacking program: Participant's Weight

(Used for the purpose of prepping weight carried in backpack)

Participant's Height *

Please list below if your child has any allergies, food related or others. If none, please state "N/A." (Ie. allergic to bees, nuts) *

Does your child carry an epipen? *

Yes

Other:

For backpacking program: Child's Backcountry Experience

Beginner - Child has never been camping in backcountry.

Intermediate - Child has gone one or two backcountry trips, and carried his/her own pack.

Advanced - Child has been on multiple backcountry trips and looking to advance particular skills.

Other:

Clear selection

Mailing Address - Line 1 *

Mailing Address - Line 2

City *

State (2-Letter) *

Zip *

Phone *

What does your child do for physical activity on a weekly basis? Please list activities enjoyed and how many hours per week. *

For backpacking program: Has your child ever had a sleepover away from family before?

Yes

Other:

Clear selection

List any physical or behavorial conditions our instructors should be aware of when working with your child (ie. Epilepsy, Sleeping disorders, asthma, nosebleeds, bedwetting, etc.). Please note certain conditions may require a medical clearance from your family physician. We will discuss with you as needed.

Please list your family physician, Child's Health Insurance Company & Policy Number *

Date of Child's Last Tetanus Shot

Please note: if your child has not received a tetanus shot, we will request you to complete one additional release form prior to their program.

YYYY

Any Recent Surgery or Illness? Please Explain.

How did you hear about InspireOut?

Is there anything else we should know about your child?

My child has permission to attend InspireOut. My child is in good health and physical fitness. I accept all financial responsibility for my child's attendance. In case of a medical emergency, I hereby authorize the physician selected by InspireOut's Program Director and others authorized by him/her to secure all proper and required treatment for my child. I agree to the release of any records necessary for treatment, billing, or insurance purposes for my child. By typing your name in the box below, you are signing in agreement to these statements. *

Parent's Full Name (Signature)

Signature Date *

YYYY

I agree that any photos taken by InspireOut, or others authorized by them, as well as any photographs, videos, writing, artwork, and/or testimonials submitted by my child to InspireOut shall be the property of InspireOut and may be used by InspireOut at its discretion for marketing and/or advertising purposes. I hereby consent to and authorize such use without restriction.

Parent's Full Name (Signature)

Signature Date

YYYY

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