Enrollment Application - Gap Year & Semester

Page 1

Please have your medical history and background information ready!

This form will take about 10-15 minutes to complete.

Participant Details

Participant Address

Street

Town/City

State/Region

Zip/Post Code

Country

Which course are you applying for?

Choose one of the following:

Where Heard?

How did you hear about us?

Promo Code (if applicable)

Please explain how you heard about our programs:

Did anyone refer you?

YesNo

If yes, who?

Is this individual an alumni of OBCR?

YesNo

Passport & Visa

All persons arriving in Costa Rica are required to show:

A roundtrip/outbound ticket with a departing flight no more than 90 days after your arrival.
A valid passport with an expiration date 6 months after your date of departure. (For example, departing Costa Rica June 30, 2021-passport must be valid until at least December 31, 2021.)

European, British, Canadian, and United States citizens are eligible for a 90 day tourist visa upon entry to Costa Rica. This is a free renewable Visa and will be issued when the participant arrives in Costa Rica. If you have any questions about visas, please visit your country's embassy website for Visa requirements, restrictions, and prices.

Does the participant have a valid passport?

YesNoIf you answered no, as soon as you receive your new passport please send a photo or scanned copy to our team at [email protected].

Issuing Country

Passport Number

Passport Expiration Date (MM/DD/YYYY)

COVID-19 Vaccination Status

We encourage everyone to be fully vaccinated before the start of our programs (all of our staff are fully vaccinated!), but not required to at this time. Be aware that vaccine requirements may change in the future.

Please indicate your vaccine status below:

I am fully vaccinatedI will be fully vaccinated at least 14 days prior to programI will not be getting vaccinated

Required: Emergency Contact Information

Primary Emergency Contact

**This MUST be an immediate family member—preferably a parent/guardian.

Full Name

Relationship

Mobile Phone

Home Phone

Work Phone

Street

City/Town

State/Region

Zip/Post Code

Country

Secondary Emergency Contact

**This MUST be an immediate family member—preferably a parent/guardian.


Full Name Relationship Email Mobile Phone Home Phone Work Phone

Street

City/Town

State/Region

Zip/Post Code

Country

Tertiary Emergency Contact

Full Name

Relationship

Mobile Phone

Home Phone

Work Phone

Family Relation Notes

Are there any family relations we should be aware of if we need to be in touch with your emergency contact(s)? If yes, please elaborate.

Page 3

Code of Conduct

I will:

Respect the places and the people with whom I come in contact on my course
Not bring, purchase or use alcohol, tobacco products or illegal drugs during any portion of course
Not engage in any conversation topics or actions that knowingly intimidate, exclude, or alienate other members of my group
Be responsible for my personal belongings and equipment and will not hold OBCR or my instructors responsible for their loss or damage due to my negligence or neglect
Treat all equipment provided by OBCR with care
Refrain from use of harmful or abusive language while on course
Be an active participant on my course and will do my best to engage in new activities, work as part of a group and follow instructions
Obey all policies and safety guidelines established by my instructors
Not engage in or display any exclusive relationships; no kissing; no romantic interest, no engaging in any sexual or romantic activity, and not exclusively spending time with another person. This applies equally to same sex and opposite sex individuals
Never display any aggressive behavior toward anyone in my group or my instructors

I acknowledge that I understand that my attitude and behavior are critical to the success of this course. For the good of this course, myself, and my fellow group members, I agree to abide by the Code of Conduct as described above. I understand that if I break one of these rules, I am subject to termination of course without refund.

I Agree

Terms of Service

Please read and acknowledge our Terms of Service.
I have read and understand the Terms of Service regarding the release of liability, assumption of risk, and immunization waiver and agree to it of my own free will and without reservation.

Yes

Media Release

I grant to Outward Bound Costa Rica (OBCR) the right to use my image and name in all forms and media including social media, marketing materials and additional assets. I waive the right to approve versions of my image used or the written copy that may used in connection with the images.

YesNo

Signatures

I certify the information I provided on this form is true and correct. I agree to Outward Bound Costa Rica's Terms of Service and Code of Conduct and acknowledge my accordance by signing and dating the Enrollment Form electronically.

I Agree

Participant's Name

Participant's Electronic Signature

Are you under 18?

Yes

Parent or Guardian's Name

Parent or Guardian's Electronic Signature

74699

Wilderness First Responder	Whitewater Rescue Technician
Technical Rope Rescue Operations	CPR
Scuba Diving	Rafting Guide
First Aid	None

ADD/ADHD	Depression	Anxiety
Panic Attacks	Learning Disability	Autism
Hearing Impairment	Vision Impairment	Kidney Problems
Thyroid Problems	Endocrine Problems	Dental Problems
Intestinal Problems	Stomach Ulcers	Skin Problems
Head Injury	Broken Bones	Neck Problems
Back Problems	Arm Problems	Shoulder Problems
Knee Problems	Ankle Problems	Leg Problems
Foot Problems	Circulation Problems	Bleeding Disorder
Anemia	Jaundice	Hypoglycemia
Diabetes	High Blood Pressure	Heart Disease
Heart Murmur	Heart Palpitations	Irregular Heartbeat
Heartburn	Chest Pain	Asthma
Frequent Shortness of Breath	Frequent Dizziness	Sensitive to High Elevations
Motion Sickness	Intolerant to Cold Temp	Intolerant to Warm Temp
Heatstroke	Tuberculosis or Positive TB test	Active Hepatitis
History of Hepatitis	Use of Medical Equipment	Seizure(s)
Epilepsy	Cancer	Muscle Cramps
Menstrual Problems and/or PMS	Bladder Infection	Difficulty Urinating
Unexplained Sweating	Obesity	Currently Pregnant
Active Bedwetting	Anorexia Nervosa	Bulimia
Headaches	Frost Bite	Any Other Conditions
Additional Mental Health Symptoms/Diagnoses

Enrollment Application – Gap Year & Semester

Enroll Now

Gap Year & Semester Enrollment Application

Page 1

Page 2

Page 3