Spring 2025 - PODS 5th and 6th Grade

Pacifica's Adventures in Learning (PALS) Application
Pacifica’s Adventures in Learning Day is designed for home-based learners to get outside, explore, and experience hands-on learning in nature.

Each Monday, students embark on a new adventure as they explore, learn, and connect with the world around them. The day is split into two halves: the first half is dedicated to outdoor education and fun! Students will hike through nature, identifying and cataloging plants, birds, and wildlife along the way. They'll dive into local history and culture, engage in team-building activities, and participate in sharing circles—all while developing social-emotional skills and a sense of connection to the land.

The second half of the day focuses on hands-on, project-based learning. Students will collaborate with local artisans on creative endeavors such as pottery, sewing, weaving, wool felting, and more. These activities offer opportunities for artistic expression and craftsmanship.

Throughout the day, students will be grouped by age to ensure they engage deeply with the material at their level.

The goal of this program is to provide home-based learners with a chance to immerse themselves in nature, foster healthy social-emotional growth, build lasting friendships, and gain valuable life skills and unforgettable experiences.

Optional Add-On: Before the day begins from 9am-10am, we will be hosting a Mindfulness Class. During this hour, students will explore being present in mind, body, and heart through mindfulness practices and yoga. Classes will include sit spots in nature, sensory awareness practice, and social-emotional learning.
- Ages: 5-13
- Instructor(s): Kris Dubenic, Corbin Brashear, and Vanessa Redding
- Areas of Study: Nature/Ecology, Social-Emotional Skills, Teambuilding, Art, Collaborative Play, Science, Social Science and Geography
- Date(s): Every Monday from March 10 through June 2, 2025.
- Session: 12 week session
- Time: 10:00 am - 3:00 pm
- Location: Pacifica: A Garden in the Siskiyous, 14615 Water Gap Rd, Williams, OR 97544
- Tuition: $375 total. $315 + $60 supply fee. This registration fee includes a $60 supply fee for your child for all of the amazing projects they will be doing.
  - Sibling Discount: Each additional child in one family gets $50 off tuition.
DISCLAIMER: Due to the nature of our outdoor program, which involves various physical activities and an increased level of risk, we may face challenges in supporting students with certain special needs. While we are committed to providing a safe and enriching experience for all students, the level of supervision and individualized support required for children with specific behavioral or emotional needs may exceed our current staffing capacity. We encourage families to email us at education@pacificagarden.org to discuss their child’s needs with us in advance so we can assess whether our program is a suitable fit.
Are you from a home-based learning group?*

REACHTeach NorthwestLogosNone (N/A)Other
Make sure you have submitted your pre-approval to REACH from this program. Once Pacifica receives confirmation from REACH, we will invoice REACH and it guarantees your spot.

USE COUPON CODE: REACH100 at payment to register your kid(s).

My Products

PALS Spring 2025 (12-Week Session)Registration for one (1) student to attend PALS Spring 2025 Session. Price includes supplies.

$375.00

Additional Student(s)Select this option and use the dropdown box to select the quantity of additional siblings. Additional student(s) must be in the same household. Do not select this option if you are only registering one child.

$325.00 Quantity

Mindfulness and Yoga Class (Optional)Drop the kids off early for a bonus mindfulness class from 9 am to 10:00 am. During this hour, students will explore being present in mind, body, and heart through mindfulness practices and yoga. Classes will include sit spots in nature, sensory awareness practice, and social-emotional learning.

$40.00 Quantity

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Total

$0.00

Payment Methods

Credit Card

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ACH Bank Transfer

Student Information
Student's Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Students must be between 5 and 13 years old,
If you selected additional student(s), please add the additional names below. Add the last name if different than the student listed above. Each student must be between 5-13 years old to participate and belong to the same household.
Additional Students
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I agree to receive Pacifica emails about news, events, and education activities.
Emergency Contacts
The parent or guardian completing this form will automatically be the first emergency contact. If you are not available, please list two additional contacts that we can call in case of an emergency.

Please notify this emergency contact of your child/dependent's PALS dates and that they are listed as an additional emergency contact.
Please list TWO Emergency Contacts. Include their Name, Relationship, Phone Number*
Legal parents/guardians are contacted first whenever possible.*

In case of medical or surgical emergency, I hereby give permission to Pacifica staff to arrange transport for my child, as named above, to the hospital for evaluation by a physician.
Who else has permission to pick up your child from Pacifica?
List first and last names of authorized personnel.
STUDENT HEALTH INFORMATION
Please provide any health information needed to maintain the health and safety of your child during their time at Pacifica. Health information shared will remain confidential. Especially note any health, emotional, or physical problems.
Please check any that pertain to your child's health:*

Not Applicable (N/A)Asthma or other breathing problemsBowel/Bladder ProblemsDiabetesEmotional/Behavioral/Learning concernHay FeverHearing ProblemVision ProblemsMobility IssuesPhysical Injuries (recent)Seizure DisorderSkin ProblemsSleep WalkingOther
Please share any information needed to best care for your child:
Applicable health concern needing treatment, any chronic illness, surgical procedure, activity restrictions or concerns, and any other needs we should know about (privacy needs, anxiety/nervousness, behavioral problems, etc). This information is confidentially shared with Pacifica staff to accommodate your child's needs.
OVER-THE-COUNTER (OTC) MEDICATION

AUTHORIZATION FORM
For the relief of minor health problems that might temporarily affect your child’s comfort while at Pacifica, 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 Pacifica 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.
Authorization to administer OTC medications while at Pacifica*

YesNoSome
Please list any specific instructions for OTC medication:
Any known drug allergies?*

YesNo
Please list any known drug allergies:
Dietary Restrictions or Food Allergies
Please list any dietary restrictions or food allergies: *
Type "NONE" if there are no dietary restrictions or allergies.
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 to promote Pacifica programs. Use or release may include a child’s name, picture, and/or video appearing in Pacifica promotional materials prepared for the purpose of informing the community about the Pacifica events. Pacifica materials may discuss some aspect of our programs 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.
ACKNOWLEDGEMENT OF RISK AND RELEASE FROM LIABILITY PACIFICA INDOOR AND OUTDOOR ACTIVITIES
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.
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Pacifica's Adventures in Learning (PALS) Application

Payment Methods

Student Information

Parent/Guardian Information

Emergency Contacts

STUDENT HEALTH INFORMATION

OVER-THE-COUNTER (OTC) MEDICATION

Dietary Restrictions or Food Allergies

STUDENT MEDIA RELEASE FORM

ACKNOWLEDGEMENT OF RISK AND RELEASE FROM LIABILITY PACIFICA INDOOR AND OUTDOOR ACTIVITIES