Youth Survival Camp Registration (July 12-16/22)

All registration forms will remain confidential with GCT3 and Green Adventures. If you have any questions please reach out to Breeze (431)777-0047 or Corin (807)464-6604 (GCT#3 Leads) by call or text

Question Title

* 1. What is your name and community?

Question Title

* 2. What is your Birthday (Must be 18+ prior to event)

Date / Time

Date

Question Title

* 3. Personal Contact Information

Name

Address

Address 2

City/Town

Email Address

Phone Number

Question Title

* 4. Emergency Contact Information

Name

Address

Address 2

City/Town

Email Address

Phone Number

Question Title

* 5. Would you need assistance with transportation to and from your community?

Yes (if yes, GCT3 will reach out to you)

Question Title

* 6. Rate your General Health (1 being poor- 5 being excellent)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 7. If you have any physical or psychological limitations describe below.

Question Title

* 8. Rate your swimming experience (1 being poor- 5 being excellent)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 9. Any dietary restrictions or considerations?

Question Title

* 10. Any allergies?

Question Title

* 11. Do you take any required medications? (Please Specify below)

Question Title

* 12. Are you Pregnant?

Yes

Question Title

* 13. Any Medical Conditions?

Question Title

* 14. Are you susceptible to any below?

nose bleeds

fainting

headaces

colds

sinus problems

Other (please specify)

Question Title

* 15. Do you have a history with (Select Below)

Cold Injury (Frostbite, trenchfoot, etc)

Heat Disorders (Hyperthermia, heat or sunstroke)

Altitude Illness

Question Title

* 16. Do you sunburn easily?

Yes

Question Title

* 17. What is you susceptibility to infection? (wounds, urinary tract, sinus, pulmonary system, etc)

Low

Moderate

High

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

* 18. Do you use antibiotics for infections?

Yes (Please bring supplies required, guides and staff will be able to carry it for you)

Question Title

* 19. Please select all shots that you have received in the last 10 years (requirement to attend) below

Tetanus inoculation or booster

Diphtheria inoculation or booster

Polio inoculation or booster

Covid Immunization shot

Question Title

* 20. By typing your name and todays date in below, you are agreeing that you have truthfully disclosed all information requested in the above questions. You also understand that withholding such information may contribute to injury or illness and that you are compromising your care in any events that that may occur. If any information above change please notify the staff and guides immediately.