Experience Learning · Yurt Build Sign Up

When are you available?

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The entire time

Part time

What dates are you available?

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Contact Information

Name

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First Name

Last Name

Date of Birth

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(mm/dd/yyyy)

Gender Identity

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Age

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Email

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Verify Email

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Main Phone Number

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Emergency Contact Name

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First Name

Last Name

Emergency Contact Phone Number

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Physician Name

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First Name

Last Name

Physician Phone Number

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Insurance Company

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Insurance Policy Number

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Dietary Restrictions and/or Allergies

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Please list all allergies to insects, foods, medications, etc., be sure to include any dietary restrictions as well (vegetarian, gluten or lactose intolerant, vegan, no pork, etc.). We may not be providing food, but it is important for us to know of any known medical considerations.

Current and Recent Medical Conditions

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Please list all medical conditions that you have been diagnosed or treated for within the past year. Include any injuries, illnesses, psychiatric treatment, counseling, eating disorders, attention deficit disorders, etc. If diabetic, please include contact information for diabetic nurse/physician.

Medications

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List all medications that you are currently taking. If bringing medications, make sure they are in their original containers with physician’s dosage directions. If you are bringing an Epipen, please bring two, as well as the appropriate dose of oral Benadryl due to our remote location.

Date of Last Tetanus Shot

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(mm/dd/yyyy)

Has the volunteer ever had any history of anaphylactic reaction?

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If yes, please list what the reaction was to

Initial here to agree that volunteer may consume peanut products.

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Has the volunteer been vaccinated against COVID-19?

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This is for contact tracing purposes only

Yes

No

Prefer Not To Answer

How many doses have been received?

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One Dose

Two Doses

Two Doses + Booster

Permission to Use Images

Experience Learning relies on the use of images of program activities and participant feedback for recruitment purposes, as well as to report to and solicit financial donors. Experience Learning staff members often take photographs informally throughout a program and these serve as our image library. Also, participants are asked to complete evaluations at the end of a course. By signing below you agree that Experience Learning has the right to use pictures or statements by, of, or about you for aforementioned uses.

Initial Here to agree to permission to use images

Nondiscrimination Policy

Experience Learning follows a policy of uniform nondiscrimination with regards to sex, age, race, religion, and country or origin.

Medical and Liability Release

I understand that Experience Learning programs may involve canoeing, hiking, camping, backpacking, stream sampling and other outdoor activities. I understand the inherent risks involved in these activities and that unanticipated dangers may arise. I voluntarily assume all risk of loss, damage, illness or injury, including death, which may occur while I am participating in any activity or event associated with Experience Learning or during such times I am under the supervision of any employee or agent of Experience Learning. I agree to hold harmless and release Experience Learning and its volunteers, employees, and agents in any location where activities are conducted. If a medical emergency does occur and I am unable to respond or cannot readily be consulted, Experience Learning may select any licensed physician to secure and administer medical treatment, including hospitalization and surgery if and as needed. I understand any medical expense so incurred will be my financial responsibility. I have listed all the information concerning allergies, medical history or conditions, dietary restrictions and regular medication that I may take.

COVID-19 Release

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Experience Learning has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Experience Learning can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Experience Learning staff.
I voluntarily seek services provided by Experience Learning and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19.

More regularly updated information on our COVID-19 policies can be found here.

Signature

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