Ashokan Center Student Information Sheet

Sorry, this link is not a valid school. Please check your link or contact education@ashokancenter for more info.

WELCOME PARENTS/GUARDIANS & CHAPERONES!

” para español, haga clic en la bandera en la parte inferior derecha de la página. “

Wondering what to pack for the trip? Click below

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

**STOP** This link appears to be for a fieldtrip date that has expired. Please contact the trip coordinator from your school to recieve an updated link.

In order for your child to participate in any programming here at Ashokan, you must submit the following form.

PLEASE NOTE: You may use the “Save and Continue Later” link at the bottom of this page if you are unable to complete all fields at this time. (If you use this feature, you will be asked to provide an email in order to receive a link).

This field is hidden when viewing the form

User Role

This field is hidden when viewing the form

Page Embed

This field is hidden when viewing the form

Product Type

Select

– No Results – |

This field is hidden when viewing the form

Admin

admin

Click to fill out form on behalf of student (not parent or guardian)

Add on behalf of student

This field is hidden when viewing the form

Type*

Student

Chaperone

This field is hidden when viewing the form

Add-on

Product

This field is hidden when viewing the form

End Date

This field is hidden when viewing the form

School/Group name

School/Group Name*

Name of Person filling out this form

First Last

Email of the person filling out this form

This field is hidden when viewing the form

Upload Signed Waivers

Drop files here or

Max. file size: 50 MB.

This field is hidden when viewing the form

Upload Additional Forms

Drop files here or

Max. file size: 50 MB.

This field is hidden when viewing the form

School Name & Dates

this will be hidden?

This field is hidden when viewing the form

Confirmation Agreement Entry ID

This field is hidden when viewing the form

Trip Dates*

This field is hidden when viewing the form

Trip Coordinator*

This field is hidden when viewing the form

Trip Coordinator Email*

This field is hidden when viewing the form

Medical Coordinator Email

This field is hidden when viewing the form

Trip Type*

Basic Information

Parent or Chaperone Name*

First Last

Parent or Chaperone Email*

Parent or Chaperone Phone

Do you have any special dietary needs or food allergies

Yes

This field is hidden when viewing the form

Second Parent Email*

This field is hidden when viewing the form

Second Parent Phone

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Information

Student Name as it appears on Birth Certificate (Legal Name)*

First Last

Preferred Name if different then above

Gender*

Male

Female

Nonbinary

Student Pronoun

Student Birthday*

Grade

This field is hidden when viewing the form

Age

T-shirt Size*

Student Medical Info

Family Physician*

Physician Phone*

Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Provider*

Insurance ID*

Health History*

Other Health History info

Does this person have any of the following?

Food and/or Drug Allergies

Dietary Restrictions

Severe allergies unrelated to food and drug

This student is currently taking medications

Severe allergies unrelated to food and drug*

Please offer as much detail as possible.

What medications does your child currently take*

Please provide the following for each: Name of Medication, How taken (orally, topically, etc.) Dosage How Often (frequency including time of day)

Dietary Needs

Information shared here will be seen by Ashokan staff and possibly other members of your community. Please do not share any sensitive private information here:

Food/Drug Allergies*

Please include all known food and drug allergies including severity

Dietary Restrictions

Gluten Free

Dairy Free

Vegetarian

No Red Meat

Additional Dietary Preference Information (Please indicate whether the dietary restriction is life threatening, a sensitivity, or a preference)*

This field is hidden when viewing the form

Admin Dietary Restrictions

Does your child have any food allergies or restrictions?

This field is hidden when viewing the form

Admin Medication List

Medication

Dose

Route

Times

When

Notes

Med Rec

This field is hidden when viewing the form

Medication List Array

This field is hidden when viewing the form

Admin Health Status

Awaiting Review

In-Progress

Incomplete

Completed

This field is hidden when viewing the form

Admin Form Return

Medication and OTC Form

This field is hidden when viewing the form

Admin Rescue Meds

Epi Pen

Inhaler

Seizure Medication

Emergency Contacts

Emergency Contact 1 Name*

First Last

Emergency Contact 1 Phone*

Emergency Contact 1 Relationship to Student*

Emergency Contact 2 Name*

First Last

Emergency Contact 2 Phone*

Emergency Contact 2 Relationship to Student*

This field is hidden when viewing the form

Emergency Contact*

Please submit at least one contact name & phone number to be used in an emergency.

This field is hidden when viewing the form

Admin Notes

Has this student attended an event at Ashokan before?*

Yes

Please choose all that apply*

This student has been on an Ashokan Field Trip

This student has attended YESS in the past

This student has attended a public event

General Waivers

Authorization to Consent to treatment of a minor temporarily separated from his/her parents:*

I, the undersigned, parent or legal guardian of this student, a minor, am familiar with the program and the general nature of activities planned during their trip to The Ashokan Center, and to the best of my knowledge the above information is correct. My child is capable of participating in and has permission to engage in all activities. I do hereby authorize, our schools Trip Coordinator as our agent(s) to consent to any diagnostic procedure or medical care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician at the nearest hospital with facilities appropriate to my child’s injury/illness. This authorization shall remain effective until (day after the last day of the trip unless sooner revoked in writing delivered by said agent(s).

Student Waiver of Liability*

I hereby accept any and all responsibility for, and assume the risk of any and all injury or damage to my dependent children which might arise directly or indirectly as a result of, and or participation in, all of the Ashokan Center’s programs, including, but not limited to challenge course activities. I hereby expressly release, indemnify, discharge and hold harmless from any liability whatsoever the Ashokan Center, their officers, directors, trustees, agents, and/or their employees, volunteers with respect to any injury, disability, or death in their capacities as representatives of The Ashokan Center. I certify that I am familiar with the contents of this release, that I have read and understand the same, and that it is my intention by signing this release that the same is binding not only of me, but my heirs, administrators, executors, successors and assigns.

Media and Testimonial Release*

I authorize the Ashokan Center to photograph and/or film my child during their Ashokan Field Trip. I further authorize the use of the photo/video content for the furthering of the Ashokan Center’s nonprofit mission, ie: grant applications, marketing materials, website.

Photo/video of my child may be shared only in a privately linked trip gallery page.

I do not consent to my child being photographed.

Contact Opt-In*

I consent to being contacted by the Ashokan Center via email, phone, or mail. I may remove myself at any time.

Yes

Not at this time

This field is hidden when viewing the form

Roster ID

This field is hidden when viewing the form

Roster id

This field is hidden when viewing the form

Bunk ID

Signature*

Comments

Will this child need medication while they're here?

The Medication Authorization Form is required only if a student needs to take ANY type of medication. This form or a similar one from your doctor's office, must list specific medications, the dose, the route, and the time administered for each and every medication in order for us to legally administer them. This also applies to any OTC medications, including what we keep in stock here (Ibuprofen, Acetaminophen, Benadryl (both oral and topical cream), loratadine (Claritin), antibiotic cream and hydrocortisone ointment).

The Medication Authorization Form requires both the parent or legal guardian’s signature as well as the Dr.’s signature and stamp.
English: Click here to download Medication Permission Form (optional)
Spanish: Click here to download Medication Permission Form (optional)
We can also accept a form provided by your physician

I would like to bypass uploading the Medical Authorization form at this time. I am aware that Ashokan Center can not provide my child over-the-counter medications (Tylenol, Benadryl, etc.) without this Medical Authorization Form. I am aware that Ashokan cannot administer prescription medication without this Medical Authorization form.

Medication Requirements*

All prescription medications must be in their original labeled pharmacy containers. All OTC medications must be new, unopened in their original containers and be within their expiration date.

Any loose, unmarked medications provided in ziplock bags or weekly pill dispensers will not be accepted and will be immediately returned to school staff.

I acknowledge that Ashokan can not legally dispense any medication that does not comply with the requirements above.

Med Form(s) Requirements*

Med Form(s) must:

list specific medications, the dose, the route, and the time administered for each and every medication.
This also applies to any OTC medications, including the seven we keep in stock here- (Ibuprofen, Acetaminophen, Benadryl (both oral and topical cream), loratadine (Claritin), antibiotic cream and hydrocortisone ointment.
Include the prescriber’s signature and stamp as well as the parent’s signature granting us permission to administer.
Be less than one fiscal year old.

I acknowlede that the forms being uploaded comply with the requirements above

Please Upload Medical Authorization Form for use of prescribed and over-the-counter medications

PLEASE NOTE: YOU MAY USE THE RED “SAVE AND CONTINUE LATER” LINK AT THE BOTTOM OF THIS PAGE IF YOU ARE UNABLE TO COMPLETE THE MED FORM AT THIS TIME. (IF YOU USE THIS FEATURE, YOU WILL BE ASKED TO PROVIDE AN EMAIL IN ORDER TO RECEIVE A LINK).

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 50 MB.

This field is hidden when viewing the form

School Nurse Med Form Review

Not Reviewed

Needs Further Review

Approved

CAPTCHA

This field is hidden when viewing the form

School Med Notes

This field is hidden when viewing the form

OTC Medictions Recieved

This field is hidden when viewing the form

Remove

Delete