Back to the Wilderness Intersession 7th Grade Permission Slip

Transcription

1 Advisor: Student: Back to the Wilderness Intersession 7th Grade Permission Slip Parent(s)/Guardian(s) Permission for Participation and Authorization for Medical Care Intersession Logistics: Map of Site: Dates: Wednesday, June 7th-Thursday, June 8th, 2017 Location: Alliance Redwoods Conference Center, Occidental (82 miles from EBIA) Drop off: 7:30-9:00 am at EBIA on June 7th Pick up: 3:00-3:30 PM at EBIA on June 8th (note, there is no EBIA Quest during Intersession) All transportation to and from the camping site will be done by EBIA arranged buses. Activities: Overnight cabin camping; hiking; assist with meals and clean-up; campfire time; and other activities related to environmental education, social emotional learning, and obstacle challenge activities. Supervision: EBIA staff and family volunteer chaperones who are LiveScan certified will be supervising students during this time. Students should bring sleeping bags or blankets for bunks. Swimming: Please answer both questions. Student knows how to swim. Yes No Student has permission to swim in pool with adult supervision. Yes No Volunteer Support: Please check below if you are interested in support the group in any of the following ways.**note: All chaperones must be LiveScan certified through EBIA. There is a one time fee to get certified and then the certification has no expiration.** I am interested in Chaperoning. Yes No programs@eastbayia.org for more information about chaperoning. To the Head of School at East Bay Innovation Academy (EBIA): has my permission to participate in the intersession program from June 7th - 8th, General activities to be included are overnight cabin camping, hiking, challenge course activities, campfire time, environmental education, social emotional learning, team building challenges, and assistance with meals and set up and clean up of all activities. Students advisors will be supervising in addition to other EBIA staff. Parent(s)/Guardian(s) Please Note: Section of the California Education Code states in part: All persons making the field trip shall be deemed to have waived all claims against the district, charter school, or the State of California for injury, accident, illness, or death occurring during or by reason of the field trip or excursion. Failure of student to comply with rules may result in student being sent home at parent(s)/guardian(s) expense. Field trips are voluntary and a privilege; student may remain in school at parent(s)/guardian(s) request.

2 Advisor: Student: A. Assumption of Risk: By signature hereon, parent/guardian waives liability against the school and acknowledges that the trip and its activities may expose the student to potential harm including injury or death. Check here to confirm that you have read and received instructions and requirements. Check here if child may not participate in any intersession activity. Please describe the activity(s) child may not participate in below: Check here: I understand that students will be expected to take part in all activities at all times. As an extra precaution in case of illness/injury or for disciplinary reasons, I will be available to pick up my student at any time. Authorized Signature of Parent or Guardian: X B. Authorization for Medical Care: If it becomes necessary for my child to have medical care while participating in this trip, I hereby give school permission to use their judgement in obtaining medical care for the child, and I give permission to the physician selected by the school personnel to render medical care deemed necessary and appropriate by the physician. I understand that the school carries student accidental injury insurance in an amount limited to $50,000 (applies excess of family health insurance if applicable). Student Name: Home Address: Parent/Guardian Name: Home Phone: Work Phone: Emergency Contact Name: Phone: Check here if instructions for special medical treatment and/or over-the-counter medication are on file in the school. Instructions: Check here if instructions for any food/dietary restrictions. List here Instructions: Authorized Signature of Parent or Guardian: X C. Agreement of Participation Expectation: I understand that students will be expected to take part in all activities at all times. As an extra precaution in case of illness/injury or for disciplinary reasons, I will be available to pick up my student at any time. In case I need to be reached for any reason, my phone number is:. An alternative emergency number is. Authorized Signature of Parent or Guardian: X

3 Alliance Redwoods Outdoor Education Medical Form (For office use only) Cabin # Group Name (e.g. school or church): Minor Full Name (first, middle, last): Date of Birth: Primary Emergency Contact Guardian Name (first, middle, last): Address: City: State: Zip: Home #: Work #: Occupation/Employer: Additional Emergency Contact Name (first, middle, last): Address: City: State: Zip: Home #: Work #: Occupation/Employer: Health Care Provider Medical Insurance Co: Policy #: Physician or Clinic: Phone #: Dental Insurance Co: Policy #: Dentist or Orthodontist: Phone #: Health History Indicate any conditions which apply: Diabetes Seizures Asthma Back/Neck Injuries Heart Condition Nosebleeds Fainting Headaches/Migraines Other (please state): Last Tetanus Shot: Restriction of Activities: Physical Disabilities: Allergies Food Drug Environment Other Medication Condition requiring medication: Medicine and Dosage: OTC Medications to avoid: Medical Waiver and Release of Liability on Page 2 *Signature Required* Page 1 of 2

4 Alliance Redwoods Medical Waiver and Release of Liability Please be sure to read and understand this document and sign and date at the bottom of this page Medical and Liability Release I agree to allow the ALLIANCE REDWOODS CONFERENCE GROUNDS Health Care Staff to render care to, arrange transportation for and administer over-the-counter medications to, the named minor, within the Staff scope of practice, and as deemed beneficial to the health and well-being of the named minor. I further agree that the over-the-counter and prescription medications, brought to camp will be collected by and then only administered by, the ALLIANCE REDWOODS CONFERENCE GROUNDS Health Care Staff, in accordance with all applicable prescriptive direction and/or on an as needed basis. No medications having reached an expiration date will be accepted or administered. In the event I cannot be reached by phone at the time of an injury or illness to the named minor, I hereby give, as parent/legal guardian, my permission to the doctor selected by the ALLIANCE REDWOODS CONFERENCE GROUNDS to hospitalize, access and procure necessary medical records, and secure appropriate treatment, including but not limited to, injections, anesthesia, testing, radiology, or surgery for the named minor as deemed necessary. Medical insurance coverage by the ALLIANCE REDWOODS CONFERENCE GROUNDS insurer is secondary to your medical insurance policy, and available only following the usage of your policy to the limit of your policy coverage or if you have no medical insurance of your own. I understand that in signing this form that I am providing both a Medical and Liability Release to the ALLIANCE REDWOODS CONFERENCE GROUNDS for the minor named on the front page. I hereby acknowledge that during his/her attendance at a camp session certain risks exist, which may be known or unknown at this time, and may result in physical injury or illness. In signing this Liability Release, I assume full responsibility for mitigation of such an incident, and I am granting permission for the participation of the named minor in all session related activities, unless specifically noted on this form. This release is intended to stand on the behalf of the named minor, and in place of all claims by any family member or agent. These releases of ALLIANCE REDWOODS CONFERENCE GROUNDS shall be in effect only for the duration of the camp session as indicated, and only while the named minor is on the grounds of ALLIANCE REDWOODS CONFERENCE GROUNDS, and/or under the direct supervision of ALLIANCE REDWOODS CONFERENCE GROUNDS employees. I agree that, in the event of dispute between myself as guest or parent/legal guardian of, or on behalf of, the named minor, I will submit to arbitration by an organization sanctioned for this purpose, in lieu of pursuing litigation in a court of law. I further agree as parent/legal guardian, to absolve and hold harmless the ALLIANCE REDWOODS CONFERENCE GROUNDS a Non-profit Corporation, its Board of Directors and Trustees, agents and employees against liability for; damages, losses, or injuries or illnesses to; myself, my property, or the named minor. Non-compliance with disclosed behavioral standards and instructions, written or oral, may result in disciplinary actions, up to and including, being asked to remove the named minor from the grounds. Anyone asked to leave the grounds shall forfeit all camp fees previously paid, while remaining liable for any fees due. I hereby give my permission to the ALLIANCE REDWOODS CONFERENCE GROUNDS to use photography of the named minor taken while on the grounds for promotional purposes. Participant Waiver and Liability Release In consideration of The Alliance Redwoods Conference Grounds furnishing services and/or equipment and/or using my own equipment to enable me to participate in ropes course, biking, kayaking, canoeing, rock climbing, skateboarding, inline skating, scooters, paintball games or any other activities, I agree as follows: I FULLY UNDERSTAND AND ACKNOWLEDGE THAT: A) Risks and dangers exist in my use of the equipment and my participation in the activities stated above; B) My participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability; C) These risks and dangers may be caused by the negligence of the owners, employees, officers, or agents of The Alliance Redwoods Conference Grounds; the negligence of the participants, the negligence of others, accidents, breaches of contract, the forces of nature or other causes. These risks and dangers may arise from foreseeable or unforeseeable causes; but not limited to, guide decision making, including that a guide may misjudge terrain, weather, faulty equipment, trail or river route location, and water level, risks of falling out of or drowning while in a raft, canoe or kayak and such other risks, hazards and dangers that are integral to recreational activities that take place in a wilderness, outdoor or recreational environment; D) And by my participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibilities for any losses and/or damages, whether caused in whole or in part by the negligence or other conduct of owners, agents, officers, or employees of The Alliance Redwoods Conference Grounds, or by any other person. I, on behalf of myself, my personal representatives, and my heirs hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify The Alliance Redwoods Conference Grounds and its owners, agents, officers and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my participation in any of the activities stated above, or any other activities. I specifically understand that I am releasing, discharging, and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers or employees of The Alliance Redwoods Conference Grounds. I have read this waiver and release of liability and by signing it agree, it is my intention to exempt and relieve The Alliance Redwoods Conference Grounds from liability for personal injury, property damage or wrongful death caused by negligence or any other cause. I also understand that in signing as a parent or guardian in the event of an emergency if I can not be reached, I hereby give permission to the physician selected by The Alliance Redwoods Conference Grounds staff to hospitalize or to secure proper treatment, order injections, anesthesia or surgery for my child. Signature (Parent or Guardian must sign for campers under 18 years of age.) PRINT Camper Name: School or Group Name: PRINT Parent or Guardian Name: Signature of Parent or Guardian: Page 2 of 2

5 ALLIANCE REDWOODS MEDICATION PROCEDURES If medications are brought to Alliance Redwoods, the following procedures MUST be followed: 1.) Parents of attending students will need to fill out the Alliance Redwoods medical form. a) Medical Form and Medical and Liability Waiver must be copied front to back, and on ONE sheet of paper. b) All medical forms must be signed by a legal guardian. NO FAXES OF THE MEDICAL OR WAIVER FORMS ARE PERMITTED. 2.) Each student s medicine(s) MUST be placed in a plastic ziplock bag. a.) All bags must be labeled with school and student s name. b.) Medication check-in slips (see below), with directions regarding medicine, must also be placed in bag. c.) All medicines MUST be in original prescription bottle or original over-the-counter labeled box. DO NOT SEND LOOSE PILLS, OR CONTAINERS WITH MIXED PILLS TEACHERS Place all bags of medications into ONE box labeled with school s name. Medication Check-In Camper s Name School Name: Name of Medicine As Needed Taken Daily Dosage/Time 1) 2) 3) IF SENDING AN EPI-PEN, PLEASE LIST SPECIFIC ALLERGIES: Place your student s medicine in original prescription bottle or for non-prescriptions, in original labeled box together with this form in a Ziplock bag. Place this form and medicines in a plastic Ziplock bag labeled with student s name and school name. Student Document

6 Back to the Wilderness Innovation and Nature: June Intersession 2017 Overview: Over the last week of school in June, we are headed off on camping trips. Here are trip expectations, logistics, and lists to get students and families ready to unplug from technology and explore Innovation and Nature! Trip Overview: Theme Grade Dates Location Rides 6/8 Pickup The Amazing Race 6th June 7-8 Anthony Chabot Regional Park, Oakland Buses 12:00 PM Legends of the Hidden Temple 7th June 7-8 Alliance Redwoods Center, Occidental Buses 3:00 PM Ascend 8th June 6-8 Twin Canyons Girl Scout Site, Lafayette Buses 11:30 PM Expectations: Leave electronics at home. Participate in all planned activities. Engage in the Innovator Norms: Practice kindness, conscientiousness, perseverance, curiosity, respect, citizenship and leadership. Participation Requirements: The following events or issues put students at risk for attendance. If students engage in any of these it may result in parent/guardian required to supervise for participation, not being able to attend, or restricted participation in trip. If students are suspended within 1 month before the trips they cannot attend. If students have more than 1 altercation (physical, verbal, digital) with a staff member or students their attendance will be reviewed by EBIA administration. If students have left campus without permission their attendance will be reviewed by EBIA administration. The following events or issues will result in students being sent home from camping trips. If students have more than 1 altercation (physical, verbal, digital) with a staff member, students, or parent volunteer. If students leave camping area (boundaries will be set) without permission. If students engage in unsafe behavior, such as actions that put themself or another participant in danger, and possession of any items that are inappropriate for school including weapons or illegal substances. Alternative Options: Students who remain at EBIA during the intersession trip will participate in community service at EBIA or 6th and 7th grade activities on Tuesday as decided by EBIA staff. Students who are not attending camping trips and are not at school for 3 or more days must connect with their advisor to develop an approved independent study plan for missed school days. Volunteer Update: Meeting Our Back to the Wilderness Volunteer Meeting will be held on May 24th from 6:00-7:00 PM at EBIA. Join us to prepare for volunteering for the trip! Trip administrators will be present and chaperones are expected to attend. Volunteer Opportunities Chaperones - Still room for chaperones to sign up! Get your LiveScan certification and attend the Volunteer Meeting. We are looking for daytime activity, food prep (6th and 8th grade trips), and night watch volunteers programs@eastbayia.org with questions.