Parent or Guardian Release Forms

**Si necesita este formulario en español, por favor seleccione 'Español' en la esquina superior derecha de esta página.**

Greetings Parents and Guardians,

We are excited to offer your high school student the opportunity to participate in Pacifica's Outdoor School Student Leader Program. [Click here to learn more.] This is an incredible opportunity for your student to develop valuable skills, spend time outdoors, explore our local environment, and so much more!

Before we can proceed with your student's application, we kindly ask that you submit the following forms:

• Acknowledgment of Risk and Release from Liability
• Emergency Contact Information
• Medical Authorization
• Student Behavioral Agreement
• Student Media Release Form

Once we receive these documents, we can move forward with coordinating permissions, scheduling, and preparing your child for their Outdoor School experience in collaboration with you and their high school.

Parent waivers must be signed and submitted by April 15th, 2025. Training is scheduled for Friday, April 18th, and Saturday, April 19th, 2025. Your child will be assigned an Outdoor School date based on availability and scheduling.

Thank you for supporting your student in participating in this exciting and enriching experience!

For any questions regarding accessibility or the Student Leadership Program, please message Clair at clair@pacificagarden.org.

The parent or guardian completing this form will automatically be the first emergency contact. If you are not available, please list an additional contact that we can contact in case of an emergency.

Please notify this emergency contact of your child/dependent's training and Outdoor School dates and that they are listed as a secondary emergency contact.

Please provide any health information 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 personnel and your Pacifica staff or child’s school personnel will administer prescribed medication.

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.

Select whether or not you would like your child to be able to receive over-the-counter (OTC) medication if needed. If this list contains medication you do not want your child to receive, please select the third option "some" and then explain your reasons below.

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.

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.

Pacifica's Outdoor School is a school in the outdoors, and the rules at your regular school apply while you are at Pacifica. It is important for students to remember that in order to learn and have fun, each student is responsible for demonstrating appropriate behavior.

Students will be expected to:

• Use behavior that supports learning during field study times.
• Listen to and follow instructions.
• Cooperate and participate in activities.
• Respect the rights of others to participate and learn.
• Get along with adults, student leaders, and other students.
• Cooperate with all students and staff.
• Respect nature.
• Use appropriate language.
• Follow the Outdoor School rules for behavior and safety.

Unacceptable behaviors include:

• Swearing.
• Refusing to follow instructions or directions.
• Bullying, pushing, shoving, or intimidating other students.
• Behaving stubbornly toward staff.
• Play fighting or engaging in physical horseplay.
• Disrupting Outdoor School activities.
• Refusing to participate in Outdoor School activities.

Behaviors that threaten the safety of students or staff, or put anyone at risk, will result in a student being sent home and may lead to further consequences. These behaviors include:

• Violent acts against staff or students.
• Theft or vandalism.
• Possession of alcohol, tobacco products, narcotics, or dangerous drugs.
• Possession of a weapon.
• Engaging in overt sexual behavior toward students or staff, or running away from supervisors.

Any search of personal belongings will be conducted in accordance with the school district’s student search and discipline protocol.

STUDENT MEDIA RELEASE FORM 

Photographs and videos will be taken of kids and 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.

Use or release will NOT include a child's name without additional permission granted by the parent.