Youth Backpacking Trips In Northern California

Before you begin…

Why do we require an application for our Trekkers?

Primarily as a health and safety component of planning our Treks. Our team also likes to get to know a little bit about each Trekker in advance.

How long will it take to complete the application?

45 minutes to an hour.

How does Ubuntu Treks decide which Trekkers to accept on each trek?

Generally, we accept Trekkers on a first come basis. However, we do occasionally make choices based on the distribution of characteristics within a particular Trek.

What items should I have in order to complete this application?

Insurance Card
Healthcare History
Trekker present and helping

Trekkers Name

First Name

Last Name

Nickname?

Age

Date of Birth

YYYY

Grade (upcoming year)

Trek Date Preferences

Pick Only Two

June 7 to June 10 2021

June 14 to June 18 2021

Does Trekker have their own smart phone?

Approximate screen time daily?

Favorite School Subject?

Extracurricular Interests

Include any

How many times per year does Trekker go camping?

Has Trekker been backpacking previously?

Could the Trekker currently walk 3 miles comfortably?

Is the Trekker concerned or excited about specific elements of a backpacking trip?

Swim Comfort

Please describe your Trekkers comfort and skill level in and around water

Parent Name

First Name

Last Name

Best Phone Contact (emergency)

(###)

###

####

Parent Name 2 (optional)

First Name

Last Name

Best Phone Contact Parent 2

(###)

###

####

Best Email Contact

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

OK to text?

Allergies

Please list all allergies and medications taken

Medical Conditions

Do any of the following apply to Trekker. ADD/ADHD Arthritis Asthma Athletes Foot Bed Wetting Bleeding/Clotting Disorder Bronchitis Chicken Pox Colds/Sore Throats Constipation Convulsions Diabetes Ear Infections Epilepsy Fainting German Measles Hay Fever Headaches/Migraines Hearing Heart Defect/Disease Hypertension Kidney Disease Measles Mononucleosis Motion Sickness Mumps Muscle Disease/Disorder Nervous System Disorder Sickle Cell Anemia Sinusitis Skeletal Disease/Disorder Skin Conditions Sleep Disturbance/Walking Stomach Upsets Urinary Tract Infections Wear: Contacts Glasses

Are there any special needs or accommodations requested.?

Explain any known behavioral and/or emotional problems:

Explain any operations or serious injuries:

Explain any disabilities or chronic or recurring illnesses:

Explain any activities that are discouraged or limited by your child’s physician:

Is Trekker currently taking ANY medications?

Since last health exam, has Trekker had:

A serious injury requiring medical attention? An illness lasting longer than one week? An in-patient hospital or emergency room treatment?Restrictions from participating in any activities?

Current Height:

Current Weight:

IMMUNIZATION HISTORY

Are all immunizations current?

Current Physician

Name & Contact

Current Dentist

Name & Contact

Current Insurance Policy

Please include contact and policy #

AUTHORIZATION FOR MEDICAL CARE

This health history is correct so far as I know. The person herein described has permission to engage in all activities except as noted. I hereby give permission to the First-Aider or Adult-In-Charge to provide routine health care and witness prescribed medications. I consent for my child to receive such medical treatment and/or surgical procedures as are deemed necessary in the event of an emergency and to assume liability for any medical expenses involved. This authorization extends to my child’s participation in any activity that takes place over an Ubuntu Treks organized trip that my child takes part in. Should a medical emergency arise during my child’s participation in a Ubuntu Treks activity, I understand that reasonable efforts will be made to contact me or my designated alternate at the phone numbers I have given. If it is believed my child’s life or health may be adversely affected by the delay that an attempt to contact me or my designated alternate would cause, I consent to the administration of medical treatment and/or surgical procedure deemed necessary by the medical doctor and/or medical facility and the immediate administration of life-sustaining measures deemed necessary under the circumstances. This completed form may be photocopied.

Please Select Yes that you have read the above medical consent.

Yes

Guardian Initials

Today's Date

YYYY