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Good news! You have already completed and signed the medical record for this application. This online form cannot be submitted a second time. If you need to update the medical information for this application, please contact your Course Advisor. 
Let's get started with your application!  You will need about 20-30 minutes to complete and can save your progress and resume at a later date.

Information will be kept confidential and will be used for the evaluation of your health and readiness to participate on your Outward Bound course.  






















Applicant Information


First, we'll collect some information about the applicant.




Jr, Sr, III, etc.



MM/DD/YYYY




Understanding an applicant's pronouns helps our staff provide the best support, both in preparation for course and on course. Options are included for applicants who do not identify exclusively as male or female.


Understanding an applicant's gender identity helps our staff provide the best support, both in preparation for course and on course. Options are included for applicants who do not identify exclusively as male or female.
























Providing a mobile phone enables you to opt in to receive text message notifications regarding the status of your Outward Bound application.

Opportunities to receive text message notifications regarding the status of your Outward Bound application may vary by course and location. 


Veterans Course Details


Outward Bound Veterans courses are open to active duty servicemembers and veterans of all conflicts who have deployed or have been stationed overseas as a part of their service.


Grieving Teens Course



This is important for us to know prior to interviewing the applicant.

MM/DD/YYYY



Sliding Tuition Scale


To advance our equity and inclusion efforts and remove barriers to access, this course has a sliding-scale tuition model. If paying the full tuition is not within your means, we have the funding to support you. If you can pay full or a portion of the tuition, we appreciate you doing so. As a nonprofit organization, the tuition we receive helps us support more students on course. Please take the time to reflect on what amount of tuition is accessible for you. 

It may be helpful to ask yourself the following questions*:
  • Are you and your family homeowners or landowners?
  • Have you attended private education, or have an advanced degree?
  • Does your organization cover your professional development expenses?
  • Are your bills or credit cards on autopay?
  • Can you easily access and afford healthcare services?
  • If you are a caregiver, can you easily access and afford care services for your caregiving responsibilities?
  • Do you have little or no debt?
  • Do you have disposable income?
  • Do you have a safety net of “financially stable” people in your life?
  • Do you have Citizenship in the country you live in?
These questions do not cover all circumstances, but considering them can help you decide what percent of aid you'd like to request. Here are some guidelines to help your thought process:
  • If all of your answers were yes, we suggest that you pay the full tuition. This allows us to offer this scale for those who benefit the most from our support. 
  • If your answers were mostly yes and few no, we suggest requesting around 25% of the tuition be covered by Outward Bound. 
  • If some answers were an almost evenly split of yes and no,  we suggest requesting around 50% of the tuition be covered by Outward Bound. 
  • If most answers were majority or all no, we suggest requesting 75% or more of the tuition be covered by Outward Bound. 
*These questions are based on Tanya Rumble and Nicole McVan's Community of Practice






Parent/Guardian Information (Required If Applicant is Under the Age of 18)







Jr, Sr, III, etc.









Opportunities to receive text message notifications regarding the status of your Outward Bound application may vary by course and location.












Secondary Parent/Guardian Information







Jr, Sr, III, etc.



This parent/guardian will be the primary point of contact during the enrollment process. If you would like either the applicant or the previous parent to be the primary contact, please change your response on one of the previous pages.






Opportunities to receive text message notifications regarding the status of your Outward Bound application may vary by course and location.











Emergency Contact (Other than a parent or guardian if the applicant is under 18)





Please choose an emergency contact that is different from any parent/guardians that have already been entered.




Applicant Medical History: Past & Present

Next, we'll collect medical information about the applicant. We recognize it may feel like we are asking a lot of questions.  Please take the time to read each question completely. 

It is important for us to get accurate medical information in order to help prepare and set participants up for success as well as for our staff to provide the best possible support during the course.

Your responses will be kept confidential and will help determine any additional forms we may need you to complete.  




Knowing an applicant's sex helps our staff provide the best support, both in preparation for course and on course. The intersex option is available for applicants born with a mix of male and female biological traits.

Do any of the following conditions apply to the applicant?
If yes, please use the space provided to provide additional information, including:
  • Specific symptoms that are occurring
  • How often those symptoms or conditions occur
  • How long each symptom or condition usually lasts
  • How you care for each symptom or condition
  • Date of last occurrence of each condition
  • Any restrictions




























Do any of the following conditions apply to the applicant?
If yes, please use the space provided to provide additional information, including:
  • Specific symptoms that are occurring
  • How often those symptoms or conditions occur
  • How long each symptom or condition usually lasts
  • How you care for each symptom or condition
  • Date of last occurrence of each condition
  • Any restrictions

Please indicate which conditions apply. 











Please indicate which conditions apply. 







Please indicate which conditions apply. 







Please indicate which conditions apply.













Please indicate which conditions apply. 















Please indicate which conditions apply.









Please indicate which conditions apply. 






Please indicate which conditions apply.






















Please also respond to the following questions. We will ask for more details in the following sections.





Allergies

Please list all of the applicant's allergies to medications, foods, insect bites/stings, or other substances. Click Add Another Allergy to add additional allergies.




Applicant Mental Health History: Within The Past Year

Do any of the following apply to the applicant within the last year? If yes, please describe.




































Medications

Please list all prescription and over-the-counter medications taken by the applicant including vitamins, herbal or natural supplements and inhalers. If the applicant is taking psychiatric medication, please list any medications taken or changed within the past 3 months.

If the applicant is taking prescription medications, they must bring them in ORIGINAL PRESCRIPTION BOTTLES with the physician's dosage instructions.




MM/DD/YYYY



MM/DD/YYYY

Hospitalizations/Emergencies

Please list any applicant hospital, psychiatric, or urgent care visits within the past year. Click Add Another Visit to add additional visits.


MM/DD/YYYY


Blood Pressure (Optional)

Please tell us about the applicant's most recent blood pressure reading (must be within one year of course start date). Blood pressure may be taken with apparatus at a local grocery or drug store.

Blood pressure readings are usually reflected as a systolic value (top number) over a diastolic value (bottom number). For example, if your blood pressure is 120/80, 120 is the systolic value and 80 is the diastolic value.

MM/DD/YYYY


Additional Questions





Exercise Activity




Current Physical Activity
List the applicant's physical activity, if any. The applicant will be expected to engage in rigorous physical activity during their Outward Bound experience. Click Add Another Activity to add additional physical activities.




Additional Information


Applicant Participation, Authorization and Consent for Treatment

Over the years, many students with a variety of medical and psychological difficulties have successfully completed our programs, but we must be aware of these conditions. Failure to disclose such information could result in serious harm to you (or your child) and fellow students. If you (or your child) arrive at the program start with a preexisting medical, behavioral or psychological condition which is not indicated on your medical form and you are subsequently unable to participate fully or are forced to leave the program because of that condition, you may be charged an evacuation fee and will not receive a refund of tuition.

SIGNATURE REQUIRED:
I understand the above paragraph and agree to its terms. Consent is hereby given for the applicant to attend an OUTWARD BOUND program and permission is given for any emergency anesthesia, operation, hospitalization or other treatment (whether for an emergency or not) which might become necessary. I agree to be responsible for any and all costs associated with such treatment, including the costs of evacuation, if any. All information will be kept confidential except that information may be disclosed to any medical or other provider as needed for my (or my child’s) care. If Outward Bound arranges for treatment for me (or my child) by a medical provider, I authorize that medical provider to release information about me (or my child), and my (or my child’s) condition and treatment to Outward Bound. I understand that I (or my child) may be in remote areas, several hours or days away from any medical facility or where communication, transportation, or evacuation is subject to delay.

Please type your signature below to e-sign for consent. 

Parent/Guardian Signature
By electronically typing my signature, I agree that it has the same legal effect as my handwritten signature. A child cannot sign for a parent. 

Invalid Signature Placeholder Message
Participant Signature
By electronically typing my signature, I agree that it has the same legal effect as my handwritten signature. A parent cannot sign for a child. 

Invalid Signature Placeholder Message
Please Note
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