Pacifica's Student Leader Parent or Guardian Release Forms

Greetings Parents and Guardians,

Pacifica is hopeful to have your High School Student participate in our Outdoor School Student Leader Program. Click here to learn more. This is an incredible opportunity for your student to gain skills, spend time outside, learn about our local environment and so much more.

Before we can move forward with your students application; we need you to submit the  Aknowledgment of Risk and Release from Liability, Emergency Contact, Medical Authorization, Student Behvioral Agreement and the Student Media Release form. Once we receive these documents, we can continue to work with you, your student, and their High School to coordinate their permissions, schedule and prepare your student for their experience.

 

Thank you for supporting your student in attending this incredible experience. 

Please notify this emergency contact of your students training and Outdoor School dates and that they are listed as a secondary emergency contact. 

ACKNOWLEDGEMENT of RISK and RELEASE from LIABILITY

ACCEPTANCE of RISK and RESPONSIBILITY

I am aware that this event or activity may entail risk of injury to myself or my dependent, to spectators and to third parties.  I expressly agree, covenant and promise to accept and assume all responsibility and risk or any damage to myself, my dependents, or my property arising from our participation in activities at Pacifica.  I decide to participate in and/or allow my child/dependent to participate in these activities in spite of the stated risks.

RELEASE and DISCHARGE of LIABILITY

I, the undersigned, hereby acknowledge that I have read the assumption of risk statement and fully understand there may be certain elements of risk inherent in outdoor or indoor activities which are beyond the control of the instructors, staff, agents, officers, and employees of Pacifica. 

In consideration of Pacifica furnishing services to enable myself or my dependent to participate, I hereby assume all risk to myself or my dependent or damage to property arising out of participation in this activity, including hazards associated with any defect in a manufacturer’s product.  I hereby specifically and voluntarily release Pacifica from any and all liability, including negligence (active or passive), demands or actions as to any right of action or claim to relief which may accrue to me as a result of participation in outdoor and indoor activities.

I further agree, promise and covenant to hold harmless and indemnify Pacifica from all litigation costs, including attorney fees, or from any costs incurred in connection with claims for bodily injury or property damage which I may negligently or intentionally cause to spectators or third parties in the course of my participation.

I further understand Pacifica carries no medical insurance for the protection of participants in outdoor recreation activities and any insurance coverage existing with respect to Pacifica shall not alter the terms of this waiver nor impose any liability on Pacifica.

ACKNOWLEDGEMENT of EFFECT of RELEASE

I understand and acknowledge that by signing this release I have agreed not to assert legal claims, which I might otherwise possibly assert to maintain against Pacifica, based on my or my dependent’s participation in an activity. I also understand and acknowledge that by signing this release I assume full responsibility and legal liability for the claims or other legal demands, including litigation costs, which may be asserted by spectators or other third parties against me as a result of my or my dependent’s participation.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  

I AM AWARE THIS A RELEASE OF LIABILITY AND I SIGN IT OF MY OWN FREE WILL.

STUDENT HEALTH HISTORY

 

Please provide any health infomration needed to maintain the health and safety of your student. Health information shared will remain confidential. Especially note any health, emotional, or physical problems that might require special staff planning such as food allergies, medications, or behaviors. Please do not send pain relievers, cough drops, band-aids, home remedies, etc., as Pacifica is already equipped for proper treatment of minor ailments. 

Any prescribed medications being taken by the child must be supplied from home for the entire stay, and must be in an original prescription bottle, labeled with the student’s name, doctor’s name, medication, prescribed dosage, and the condition for which the drug is given. These will be kept in Pacifica’s office or with your child's High School personel and your Pacifca staff or child’s school personnel will administer prescribed medication. 

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, and x-ray examination for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is granted to Pacifica personnel and your child's high school personnel to provide the needed emergency treatment prior to the child's admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

For the relief of minor health problems that might temporarily affect your child’s comfort while at Outdoor School, there is a small supply of common over-the-counter medications at the site. Do not send these medications with your student.

THE HEALTH HISTORY FORM IS CHECKED FOR ALLERGIES BEFORE ANY MEDICATION IS GIVEN.

Medications available at Outdoor School are:

Alcohol Wipes Aloe Vera gel – burns/sunburns

Antibiotic Cream/Ointment

Anti-diarrheal (Loperamide)

Antihistamines (Benadryl, Chlor-Trimeton, Loratadine)

Calcium Carbonate for indigestion (Tums)

Cream for athlete’s foot or ringworm (Lotrimin or Tinactin)

Cream for Chapped Skin Cream for itching (Hydrocortisone, Benadryl, Calamine lotion)

Cough Drops Glucose for diabetic emergency

Eye Drops

Insect repellent Lotion

Milk of Magnesia Non-aspirin pain/fever relievers (Tylenol and Advil)

Soap for poison oak (Tecnu)

Sunscreen

NOTE: Brand names have been listed but their generic equivalent or the same medication of a different brand may be substituted. We do not stock chewable or liquid pain relievers. If you want your child to receive over-the-counter medication, if needed, sign below. If this list contains medication you do not want your child to receive, draw a line through that medication before signing. I authorize the staff to administer over-the-counter medication (limited to those on list) as needed, to my child while at Outdoor School.

Outdoor School is school in the outdoors and the rules at your high school apply while you are at Pacifica. It is important that students remember that in order to learn and have fun, each student is responsible for demonstrating appropriate behavior. Students will be responsible for the following: 

1. using behavior that will help them learn during field study times 

2. listening to and following instructions 

3. cooperating and participating in activities 

4. respecting the rights of others to participate and learn 

5. getting along with adults, student leaders and other students 

6. cooperating with all students and staff 

7. respecting nature 

8. using appropriate language 

9. following the Outdoor School rules for behavior and safety. 

Behaviors that are unacceptable include: 

1. swearing 

2. refusing to follow instructions or directions 

3. bullying, pushing, shoving, intimidating other students 

4. behaving in a stubborn manner towards staff 

5. play fighting and physical horseplay 

6. disrupting Outdoor School activities 

7. refusing to participate in Outdoor School activities. 

Behaviors that threaten students and staff, or put students, staff, or self in danger will result in a student being sent home and may result in further consequences include:

1. violent acts against staff or students 

2. theft or vandalism 

3. possession of alcohol, tobacco products, narcotics, or dangerous drugs

4. possession of a weapon 

5. overt sexual behaviors toward students or staff; running away from supervisors.

NOTE: Any student search of personal belongings will be conducted in alignment with their school district’s student search discipline protocol. 

I HAVE READ THIS INFORMATION AND DISCUSSED IT WITH MY CHILD/DEPENDENT. MY STUDENT UNDERSTANDS AND AGREES TO FOLLOW THE OUTDOOR SCHOOL RULES OF BEHAVIOR.

STUDENT MEDIA RELEASE FORM 

Pacifica Outdoor School 

STUDENT DIRECTORY INFORMATION 

Photographs and videos will be taken of kids and camp activities. This media may be used in advertisements or social media posts to showcase the fun activities that Pacifica has to offer! Please read and fill out the media release below.

Personally identifiable information, including a student’s photograph, participation in program activities, video appearances, and receipt of awards, may be occasionally used or released as part of the Pacifica Outdoor School program. Use or release may include a child’s name, picture,and/or video appearing in Pacifica Outdoor School materials prepared for the purpose of informing the community about the Outdoor School. Pacifica Outdoor School materials may discuss some aspect of the program or may request the donation of tools, games or other materials from community citizens. Use or release also includes our website, news stories in print, social media or television media. 

I give my permission for directory information release as stated above.  I give my permission for photos and/or videos to be taken of my child.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  

I AM AWARE THIS A RELEASE OF LIABILITY AND I SIGN IT OF MY OWN FREE WILL.

I HAVE DISCUSSED THE STUDENT BEHAVIORAL AGREEMENT WITH MY CHILD/DEPENDENT AND BELIEVE THAT MY STUDENT CAN AND WILL BEHAVE ACCORDINGLY.