Group/School Name: Bay Cities Church
Program Date: July 20, 2011 

Complete as directed and return to your program planner. 

Boojum requests the following information to assist field staff in the management of specialized medical conditions that a participant 
may have. Boojum makes no determinations of fitness or ability for participation and strongly recommends that all participants 
discuss their program activities with their physician prior to attending the program. In order to better assist you in determining the 
appropriateness of your participation Boojum is available to discuss your specific program activities and requirements. All 
information will remain confidential. You should know that over the years, many students with a variety of medical/psychological 
difficulties have successfully completed our programs, but we must be aware of these conditions.


PART I General Information 

PARTICIPANT 

Name ________________________________________________ Daytime Telephone # (______)________________ 

Gender . Male . Female Evening Telephone # (______)________________ 

Height_________ Weight____________ 

Age _______ DOB ____/____/____ Address _____________________________________ Apt. ____ 

City/State/Zip ________________________________________________________________________________________ 

PARENT/GUARDIAN 

Name/Relationship:_____________________________________ 

Cell # (______)___________Home # (_____)___________ 

Work # (______)___________________________________ 

FAX # (______)____________ email __________________ 

EMERGENCY CONTACT (other than parent/guardian) 

Name/Relationship _____________________________________ 

Cell Phone # (______)__________________________________ 
Home Telephone # (______)_____________________________ 

Work Telephone # (______)______________________________ 



 

PART II Medical Information 

 A. Allergies (Including allergies to medicines, foods, insect bites/stings) 

Allergy 

Reaction 

Medication Required ( if any) 

 

NONE . 

 

 

 

 

 

 

 

 



 

 B. Current Medications (Including psychiatric medication, over-the-counter medication, inhalers) 

Medication 

Taken For: (Symptom/Condition) 

Dosage 

Current Side Effects 

 

NONE . 

 

 

 

 

 

 

 

 

 

 

 



 

 Boojum Institute recommends that all of its participants have a current tetanus immunization (within 10 years). 

Please complete second page. 


PART III Health Profile 

 
YesNoPlease v one--If yes, please describe 
1Seizure within the past 1 yearIf yes, please describe2Hospitalization/Emergency Room/Urgent Care visit within the past 1 yearIf yes, please describe3Visited a physician within the past 1 yearIf yes, please describe & provide physicians contact information4Asthma (If yes, please bring inhaler)
If yes, please describe5Mental or psychological conditionsIf yes, please describe6Chest pain/pressure, shortness of breath, rapid heartbeat, or exertional dizziness or faint spellsIf yes, please describe7Other cardiac conditions, e.g., heart murmur or other rhythm abnormalityIf yes, please describe8Current Neck/Back/Shoulder/Knee/Ankle/or other joint problemIf yes, please describe9Other medical issues/illnesses/symptoms/ requirements/prosthetic device(s)
If yes, please describe10Other dietary needsIf yes, please describe

PART IV Signature Required 

Consent is hereby given for the participant to attend a BOOJUM INSTITUTE program and permission is given for any emergency anesthesia, operation, 
hospitalization or other treatment that may become necessary. 

All information will remain confidential. Failure to disclose the above information could result in serious harm to you and your fellow participants. 

I certify that the information on this form is correct to the best of my knowledge and that there is no other medical or psychological information I am withholding that 
will in any way affect my performance while with the Boojum Institute. 

I consent to and authorize the Boojum Institute the use, reuse and/or publish photographic and/or videographic material taken of me and/or my (son/daughter/ward) 
while participating in courses and activities sponsored by the Boojum Institute. I understand that these photographs, negatives, and/or videotapes may be used in 
educational settings, and/or in professional publications and/or conferences. I further understand that these materials can be used without limitation, reservation, or 
compensation, other than the receipt hereby given. I further understand that my name and/or (my son / daughter / ward) name will be kept confidential. 

 

____________________________________________ _____________________________________________________________ ___________________________ 
Parent's/Guardian's Signature (if participant is under legal age) Parent/Guardian Printed Name Date 

 

____________________________________________________ _________________________________________________________________________ _______________________________ 

Participant's Signature Participant's Printed Name Date 

 

. I choose not to have Boojum share updates and program information with me using the contact information provided above. 

. I opt out of photo consent.