2026 Explore the Rock Registration Form

2026 Explore the Rock Registration
This program is designed for Kodiak youth entering grades 3rd through 12th in the 2026-2027 school year. There is no deadline for registration, but participants must submit a completed registration form before participating. The program will run over five weeks from July 10 to August 7. Hikes will take place on Friday from 9 a.m. to 12 p.m., starting from the KANA Wellness Center.

Hike Schedule:

July 10: Abercrombie- Cliff Side Trail
July 17: Near Island South End Trail
July 24: Coastal Trail at White Sands
July 31: Abercrombie- Lake Gertrude Loop
August 7: Termination Point

For complete details on the program, contact KANA Wellness Center at gym@kodiakhealthcare.org or 907-486-1377.
This program is funded by several State and Federal grants, and we hope to include students of all backgrounds. Demographic information is used anonymously for grant reporting.
Participant Name

First NameLast Name
Participant age:
What grade will you be during the 2025-2026 school year?
Gender
Race(s): Check all that apply

Other
Ethnicity: Check one
Have you participated in Explore the Rock before?
T-shirt size
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name

First NameLast Name
Cell Phone
Format: (000) 000-0000.
Parent Guardian Email
example@example.com
I am Interested in volunteering for Explore the Rock!
Non Parental/ Legal Gaurdians interested in volunteering please contact KANA Wellness Center at gym@kodiakhealthcare.org or 907-486-1377.
EMERGENCY CONTACT

Please do not list yourself
Emergency Contact Name

First NameLast Name
Relationship
Emergency Contact Phone Number
Format: (000) 000-0000.
MEDICAL INFORMATION
Family Doctor
Doctor Office Phone Number
Format: (000) 000-0000.
Participant's Health Insurance Name
Health Insurance Policy Number
Please list below any medications, allergies, or limitations (physical, educational, etc.) you may have that KANA staff and/or other adult volunteers may need to know about:
STATEMENT OF CONDUCT

Youth Participant and Parent/Guardian must sign
I understand that when I attend Explore the Rock I will comply with this agreement:
- I will stay with the group at all times.
- I will respect the adults attending by following directions.
- I will not criticize or make fun of other group members or use inappropriate language.
- I will not use tobacco, vapes, alcohol, or other drugs/substances during or before our outings.
- I will not litter or harm the environment.
- I will respect property, whether my own or someone else's.
- I will obey all safety instructions given to me by adult staff.
I understand that if I do not abide by the above agreement, it may result in the following consequences:
- I will only be warned once before my parents are called.
- I may be asked to take a one break from the Explore the Rock hike.
- My parents may have to pick me up, depending on the severity of the incident.
- I may not be welcome back to the program for the remainder of the time.
Participant Signature
Date

MonthDayYear
Date
Parent/Guardian Signature
Date

MonthDayYear
Date
ACKNOWLEDGEMENT OF RISK & LIABILITIY
In the event of a medical emergency, I authorize KANA or their designated agents to obtain medical treatment for the minor in the event of my absence. If I am unable to be reached, I hereby authorize the physician or hospital to which the minor is taken to perform all medical services or to have such medical services performed which in the opinion of the physician or hospital are reasonably necessary to the care of the minor.I also understand that the KANA Prevention Department is not a licensed child care center. I have carefully read this document and fully understand its contents. I am aware that this is a release of liability and indemnification, and I have signed it voluntarily. I hereby verify that I am signing this as the parent or legal guardian of the participant and that it is binding upon me, my successors, heirs, representatives, assigns and executors. I understand this agreement shall not be modified orally. This document will be kept by the KANA Prevention Department and, if requested, shall be provided to me for my records.
Participant name

First NameLast Name
Date

MonthDayYear
Date
Parent/Guardian's Signature (Must Sign if Participant is Under 18 Years of Age)
PHOTO/VIDEO RELEASE
I give the Kodiak Area Native Association (KANA) permission to use and otherwise publish, without charge or feesof any kind, the photographs, video or film or other digital or electronic recordings of me by KANA or its agents.The photographs, video or film or electronic recordings means all audio, cinematic (moving images), orphotographic images, whether film, electronic, digital, videotape, audio tape recordings, negatives, prints orotherwise, including all reproductions in any form derivative works based on any above mentioned items.

KANA may use or publish these in news releases and advertisements, its publications, its printed material, and onits website(s)/social media website(s), including but not limited to, annual reports, brochures, educational andinstructional materials, recruitment, illustrations, art, exhibits and displays. Publish means to reproduce and todistribute throughout the world, in any media whatsoever and by any and all means, methods, processes, whethernow known or hereafter invented, including but not limited to printing copies on paper and maintaining digitalcopies on KANA’s website(s)/social media website(s).

I consent that all photographs, video or film or electronic recordings of me, and all rights therein, includingcopyrights, are and shall remain the sole and exclusive property of KANA. I release and hold harmless KANA fromany and all liability, claims, damages, expenses, and demands, whether in contract or tort or otherwise, arising outof or in connection with the publication or other use of the photographs, video or film or digital or electronicrecordings of me, including without limitation, any and all claims for libel or invasion of privacy. This Authorizationand Release for Publication shall inure to the benefit of the heirs, legal representatives, licensees and assigns ofKANA, as well as to the person(s) who takes the photographs
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
IF THE INDIVIDUAL EXECUTING THE ABOVE AUTHORIZATION AND RELEASE FOR PUBLICATION IS UNDER THE AGEOF 18, THE FOLLOWING MUST BE EXECUTED BY THE INDIVIDUAL’S PARENT OR LEGAL GUARDIAN:

I represent and warrant that I am the parent or legal guardian of the individual (hereinafter “my child” or “mychildren”) who executed the foregoing Authorization and Release for Publication. Acting both for mychild/children and for myself, I consent to the execution of this Authorization and Release for Publication by mychild/children and to the grant of rights and the release of liability in this Agreement.
Printed Name and Signature of parent or legal guardian

First NameLast Name
Parent/Guardian Signature (Must Sign if Participant is Under 18 Years of Age)
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

2026 Explore the Rock Registration

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT

MEDICAL INFORMATION

STATEMENT OF CONDUCT

ACKNOWLEDGEMENT OF RISK & LIABILITIY

PHOTO/VIDEO RELEASE