Applicant Personal Information, Consent & Health Form

Note: if contact is a parent, please list BOTH parents as contacts if they do not live at the same address.

We are requesting you to voluntarily provide your health card number for the sole purpose of keeping it on record to facilitate the provision of medical services to you in the event of an emergency during the camp orientation weekend. You are under no obligation to provide us with your health card number on this form, and your application will not be rejected if you decide not to provide it to us. However, please note that if you choose not to provide your health card number and don’t bring your health card with you during the orientation camp weekend, we may not be able to expedite the provision of health care services in the event of an emergency.

Pursuant to section 42(b)* of the Freedom of Information and Protection of Privacy Act, for the duration of my studies at Algonquin College in an Outdoor Program, I consent to: - The release of my telephone number to the faculty of the department, while I am a student at the College. - The release of specific health information to faculty and instructors which may be of concern for particular course types. - The release of personal information about me in the custody of the College, including marks, teacher evaluations, attendance, etc. to potential employers for the purpose of reference as needed and on an ongoing basis.

The Algonquin College Outdoor Programs train students to be leaders and guides in the adventure travel industry. Training is a combination of in-class study and out-of-doors training. The outdoor training ranges from single day to ten-day expeditions, and takes place in remote settings where evacuation to modern medical facilities could take days. The student will live and train in extreme conditions ranging from –40C to +25C and be exposed to wind and snow, sudden immersion in cold water and/or high seas. Depending on the specific course type, students will carry 50-75 pound packs over uneven terrain, swim whitewater rapids, and portage heavy boats. On a weekly basis students will be eating and sleeping out of doors. It is expected that each student takes proper care of him or herself. Most students find the Algonquin College Outdoor Programs both physically and mentally demanding. As such, prior physical conditioning and an enthusiastic attitude are a necessity. In the interest of personal safety of both the applicant and the other students, please consider carefully the above description when completing the Health Assessment. A ‘yes’ answer will not automatically cancel an applicant’s enrollment. If there are any questions regarding an applicant’s capacity to be successful in this program, the Program Coordinator will call that applicant to discuss the concern.

The information you provide in the following pages is confidential. Specific course instructors may be informed of your medical history if there are safety concerns and their knowing is in your best interest. This form must be a complete and accurate statement of the physical and psychological factors which may affect your successful participation in the Program. Failing to disclose such information could result in serious harm to yourself and fellow students. Failing to disclose such information could also result in your dismissal from the program. By signing this form, the student agrees to indemnify and hold Algonquin College harmless if relevant information is not disclosed. Based on the information provided on this form, the applicant may be required (at the request of the Program Coordinator) to seek further assessment from a medical professional. Any costs incurred regarding any follow up requirements are your responsibility, regardless of your acceptance into any Algonquin College Program. Please sign here indicating you have read and agree to the statements above.

APPLICANT: Please circle YES or NO for each item, YES answers require detailed explanation (in space provided). GENERAL HISTORY: Does the applicant have currently or a history of:

*Note: Algonquin College and its service providers do not and cannot provide a nut free or other allergy free environment

If conditions emerge or injuries develop during the course of the program, the student may be required to seek professional medical advice as to their status and ability to participate fully. If certain conditions emerge or injuries develop that significantly compromise the individual’s long term health, other students’ safety, or the integrity of the program and courses, the student may have to withdraw from some or all aspects of the program.

I understand that risk is an inherent part of the Outdoor Training Programs and adventure activities and courses. I understand the Outdoor Programs are physical in nature and can create or exacerbate pre-existing or unknown conditions. I understand it is my responsibility to notify the Program Coordinator if my physical or mental condition changes or jeopardizes my or other’s safety. I have completed this Health Assessment Form to the best of my ability and knowledge and have not withheld any information which may compromise my safety or ability to fully participate in the Outdoor Program.