College La Vida Release Forms

Name of Participant*

First NameLast Name

Age of participant*

Birth date of participant (mm/dd/yyyy)*

Email Address of Participant*

example@example.com

Name of parent/guardian if applicant is a minor

First NameLast Name

Since La Vida’s beginning in 1970 it has had an excellent safety record. All activities are well within safety limits, and standard procedures are strictly enforced by trained instructors. The La Vida policy “challenge by choice” means that each participant determines the level and extent of their participation. The staff will encourage participants to try each activity but will not use or allow peer pressure to force any participant to do anything they would prefer not to do. We are required by law to inform each participant of the risk and danger involved in adventure activities. Therefore, this Release and Assumption of Risk Form has been drawn up and must be signed by each participant or the parents of minors.

I am aware that during La Vida activities certain risks and dangers may occur which are out of the control of the instructors. I further realize that I will be participating in activities in which the risk of an accident may be greater than in my normal way of life.

In consideration of the right to participate in such La Vida activities, I have and do hereby assume all the above risks and will hold Gordon College and the La Vida instructors harmless from all liability, actions, causes of actions, debts, claims and demands of every kind and nature which might arise in conjunction with my participation in a La Vida program. I also acknowledge the fact that the instructors have the right to terminate my participation in the La Vida experience because of my health or physical condition. I agree that the decision of the instructors shall be binding upon me.

Initial to acknowledge*

I give La Vida and Gordon College permission to use for promotional materials and for the website any and all photos taken of me during any and all La Vida activities.*

I do give permissionI do not give permission

All wilderness programs are required by law to inform and obtain permission from participants (or a parent/legal guardian if under 18) that the camper may participate in swimming at remote wilderness sites not inspected by the New York State Department of Health. Qualified La Vida staff will determine the suitability of the site at the time of each use. These sites are often remote or inaccessible to allow for prompt transfer to an emergency medical healthcare facility.

The swimmer must adhere to the rules established: no head-first diving; no jumping into the water from cliffs, trees, water flumes or rope swings; no swimming unless required supervision and equipment are provided; swim only within the designated site; water depths will not exceed five feet; no swimming at night or during thunderstorms; hazards which are marked and within the designated area are to be avoided; and each swimmer must have a buddy, and both must check with the La Vida instructor before entering and leaving the water.

Please check one*

I am aware of the conditions associated with swimming at a remote site and GIVE PERMISSION for myself (or my son/daughter if under 18) to participate in such activities.I am aware of the conditions associated with swimming at a remote site and DO NOT GIVE PERMISSION for myself (or my son/daughter if under 18) to participate in such activities.

New York State Public Health Law requires that a participant (or parent or guardian of campers under 18) who attends an overnight camp for seven (7) or more consecutive nights, complete and return the following form to the camp.

Please select one of the following options.*

I have had the meningococcal conjugate vaccine (MenACWY), for example Menactra or Menveo. [Note: The Centers for Disease Control and Prevention (CDC) recommend two doses of MenACWY for all adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age, with a booster dose at age 16. Children and adolescents with certain medical conditions may need to begin the MenACWY series at a younger age and/or receive additional doses. Consult with your child’s healthcare provider regarding any medical conditions they may have. If the first dose (or series) is given between 13 and 15 years of age, the booster should be given between 16 and 18. If the first dose (or series) is given after the 16th birthday, a booster is not needed.]I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that I will NOT obtain immunization against meningococcal meningitis disease

Date you have had the meningococcal conjugate vaccine (MenACWY) if you answered yes to the question above. *

Date

HIPAA regulations prohibit sharing of medical information regarding anyone age 18 or over without signed consent.*

I DO authorize Gordon College La Vida staff to share medical information with the emergency contact that I have provided during my involvement in a Gordon College La Vida program.I DO NOT authorize Gordon College La Vida staff to share medical information with the emergency contact that I have provided during my involvement in a Gordon College La Vida program.

The state of New York maintains strict regulations regarding the administration of medication to minors. Any participant who is under age 18 at the time of their La Vida Expedition is considered a minor and must have authorization in writing from their doctor for any medication they might need while participating in a La Vida program. This applies to both standard prescription medications and any prescribed over-the-counter types of medication (i.e. Tylenol, Advil, etc.). La Vida instructors can only administer prescribed medications to minors during their participation on a La Vida program; they are not authorized to administer any non-prescription medications to minors.

Any minor who will need to take any prescribed medication during La Vida activities is required to have their doctor complete and sign an Authorization for Administration of Medications at Camp, detailing what medications they will need, the purpose for which they are authorized to take those medications, and what the dosages should be. All medications must be stored in their original containers and will need to be turned in to the La Vida instructors at the onset of the program, along with any permission authorizations. La Vida instructors will carry all participant medications in a designated first aid kit and dispense them according to the accompanying physician’s instructions as noted on the Authorization for Administration of Medications at Camp.

Please check to acknowledge*

I have read and understand the above and will submit the required authorization form if it is needed for my child during their La Vida experience.

Please upload an image or scan of the front AND back of your current health insurance card. *

By signing this document, I confirm that I have read through this document in its entirety and the above information is accurate.

Signature of participant (or parent if participant is a minor)*

Name*

First NameLast Name

Date*

Date

College La Vida Release Forms

LA VIDA RELEASE AND ASSUMPTION OF RISK

PHOTO RELEASE

REMOTE SWIMMING PERMISSION FORM

MENINGOCOCCAL MENINGITIS VACCINATION RESPONSE FORM

RELEASE OF MEDICAL INFORMATION

NEW YORK STATE REGULATIONS FOR ADMINISTRATION OF MEDICATION TO MINORS

DOCUMENTATION OF MEDICAL INSURANCE