GYPSD Palisades Independent Student Registration Form

All information in this application is collected in accordance with the Freedom of Information and Protection of Privacy Act.
School Selection
Student Information
Do you have a friend/friends registering for the course? If so, please print their names here:
Contact Information


Phone Numbers:

Mailing Address:

Physical Address (if different than above):

Emergency Contact During Course
Phone Numbers:
Phone Numbers:
Student Experience
Can the student run 3 km in under 30 minutes?
What is the student's swimming ability?
Medical and Background Information

Outdoor activities can be strenuous and are often more physically challenging than some participants are used to. We do not want any student to engage in activities that would be detrimental to their health, or which would be opposed by their doctor because of recent illness, injury or surgery. We must be aware of ALL health conditions, which might affect the progress or welfare of the student and other students while on this course.

Background Information


Is the student allergic to any of the following? (Please list all allergies and describe nature and severity of reaction)

Medical Information

Dietary Restrictions