Get a Grip Application Package

Application Form

*Youth must be at least 12 years old by May 17, 2022 to apply.

Full name of applicant*

First Name Last Name

Age (as of May 18, 2022)*

Applicant's Pronouns (select those that apply):*

If applying before April 10, 2022: Would you also like to apply for our Take a Hike program (Dates: Tuesday and Thursday Evenings: April 12, 14, 19, 21, 26, 28, May 3 & 5). *If you indicate yes for this option, you will be considered for Get a Grip AND Take a Hike.*

Referral Source/How did you hear about us?*

Place of Residence (as of May 18, 2022)*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Do you identify as an individual within the BIPOC community? - All information will be kept confidential in accordance with federal law and does not affect your eligibility for our programs, we collect this information to provide participant demographics to our funders.

YesNoPrefer not to answer

If you answered 'yes' to the previous question, please select from list below:

Are you a first time rock climber?*

If you responded 'No' the previous question, please tell us how many days' experience you have and how long ago?

In your own words, please explain why you would like to participate in our Get a Grip program.*

Can you be available for the following dates: evenings of May 10, 12, 19, 24, 26 & June 2 (Tuesday or Thursday indoor climbs at Beyond the Crux Climbing Gym) and on Sundays May 15 & 29 (full days, outdoors climbs at Skaha Bluffs).*

Please list any known conflicts with these days:*

RENTAL INFORMATION: Please enter youth's height, weight, shirt and shoe size (for supply and rental purposes):*

Parent/Guardian Email Address (this is where we will send notice of acceptance into the program and program information once accepted)*

example@example.com

PICK UP LOCATION: Are you able to meet at one of our central pick-up locations - West Kelowna Xtreme Theatre parking lot (beside Dairy Queen), Orchard Park Mall (beside bus loop), Rutland Shell (Hwy 33 and Gerstmar), or Rutland 7-11 (Hwy 33 and Rutland Rd) for transport to the mountain?*

TYPE OF SPOT: Please indicate the type of spot you are applying for:*

Paid seat ($350/participant - invoice will be sent once participant has been accepted into the program)Scholarship seat (Free for eligible youth - please attach proof of eligibility below. To see our eligibility criteria, and approved documents, please visit http://www.elevationoutdoors.ca/programs/ (and scroll down on the web page).)Partial scholarship (if you do not meet our eligibility requirements for a full scholarship seat but would like to inquire about partial support, please select this option and we will follow up with you to discuss options!)

* If applying for a scholarship seat, please upload proof of eligibility. To see our eligibility criteria, and approved documents, please visit http://www.elevationoutdoors.ca/programs/ (and scroll down to 'Who We Serve').

Browse Files

GOOGLE CALENDAR SHARING AND JUMPSTART PERMISSION:

Elevation Outdoors has permission to share Google Cal dates with my and/or my child's email adress (leave blank below if not interested).

Parent/Guardian Email Address

example@example.com

Youth's Email Address

example@example.com

I give permission to Elevation Outdoors to contact me about future programs and opportunities that come available.*

I give permission for Elevation Outdoors to provide my contact information to the Canadian Tire Jumpstart Foundation. As partial funders for this program they like to be able to contact you directly with future opportunities.*

PHOTO AND VIDEO RELEASE - Parent/Guardian Signature

Elevation Outdoors has permission to use my or my child’s photograph/video/audio recordings to promote the organization. I understand that the images may be used in various formats not limited to print publications, online publications, presentations, websites,and social media. Clear

CONTACTING YOUTH: Elevation Outdoors has permission to contact my child by phone (text or call) to confirm program attendance and to communicate with as need arises, during or between program dates. If you do not want this - leave this section blank.

Area Code Phone Number

Dear parent or legal guardian, Elevation Outdoors is running our "Get a Grip" rocking climbing program this Spring for youth in the local area. The program involves teaching young people how to climb starting from an introductory level. The program will run primarily at Beyond the Crux Climbing Gym in Kelowna, with 1-2 trips to an outdoor climbing area with a certified guide from Hoodoo Adventures to go climbing outdoors. This letter is to inform you of the program and the expressed interest, as well as the inherent risks in the activity of climbing. Injury to participants is always a possibility when engaging in climbing. These risks include, but not limited to: falling, mechanical failure of the equipment; loss of balance or control; variable and difficult climbing conditions; collision with walls, climbing holds, exposed or hidden structural supports or beams or floor; rope abrasion, entanglement and other injuries resulting from activities on or near the climbing wall such as, but not limited to climbing, belaying, rappelling, lowering on ropes, rescue systems and other rope techniques; injuries resulting from falling climbers or dropped items, such as, but not limited to ropes, auto belays, climbing hardware or wall parts; failure of ropes, harnesses, slings, climbing holds, anchor points, or any part of the climbing wall; collision with other equipment or structures; collision with other persons; illness or trauma; the proximity of medical care which may or may not be readily available; the failure to act safely or within one’s own ability or to stay within designated areas; negligence of other climbers and/or other persons; and negligence on the part of Elevation Outdoors Experiential Programs Association or its staff and volunteers, including the failure on the part of Elevation Outdoors Experiential Programs Association or its staff to safeguard or protect from the risks, dangers and hazards of the activities. We are requesting that you fill out the form below stating that you have read and are aware of the inherent risks of this activity before your child is permitted to participate in the program. It is our intention to create a long-lasting, learning experience for the young people involved and we will be taking their safety very seriously.*

I have read the above statement and understand the inherent risks in the activity of rock climbing, we well as the risks of participating in the program.

Parent/Guardians Full Name*

First Name Last Name

Please Read and Sign - Parent/Guardians Signature*

I have read the above letter and understand the inherent risks in this activity, as well as the risks of participating in the program. I give my child permission to participate with this in mind. Clear

Please Read and Sign - Participants Signature*

I have read the above letter and understand the inherent risks in this activity, as well as the risks of participating in the program. I give my child permission to participate with this in mind. Clear

Participants Name*

First Name Last Name

Participants Date of Birth*

Date

Participants BC Care Card Number*

Please provide the correct care card number

Parent/Guardians Name*

First Name Last Name

Parent/Guardians Phone number - Provide preferred contact number*

Area Code Phone Number

Parent/Guardians Alternate Phone number - provide a second number to be reached at (Work, Home, Cell)

Area Code Phone Number

Emergency Contact - Provide who we should call in case we cannot reach you in case of emergencies.*

First Name Last Name

Emergency Contact Phone Number - Please provide the number of the person listed above.*

Area Code Phone Number

Has you child ever suffered from Asthma?*

If Yes, please provide if they have medication and what it is/usage.

Does your child suffer from any allergies?*

If yes please list what they are and any medications they take, if it is anaphylactic and if they have an EpiPen.

Does your child suffer from any of the following?

Please select any/all that apply. Hold Cntrl or Command to select multiple entries.

If you selected any of the above options, please provide more information about them below.

Please let us know what the issue is/was, any medications they are on, and best practices for managing it.

When was the participants last Tetanus shot?*

Answer as accurately as possible. If not within the last 10 years, participant may receive a tetanus injection by a medical officer if they receive a tetanus prone wound.

Is your child on any ongoing medications?*

Please provide details of medications, dosage, and frequency taken.

If you answered yes to the above question, do you give permission to your child to self administer these medications?

If no please explain.

Please select any of the following non-prescription medications you give permission for your child to receive if needed.*

Hold Cntrl or Command to select multiple options.

Is there anything about your child's situation that we need to be aware of in regards to his/her participation in this program? Is there anything that may impact others in the program we need to be aware of?*

Example - Behavioural, Dietary, or Medical concerns

In the case of accident or illness, I authorize the caregiver to administer first aid and/or be taken to the nearest emergency centre. I consent for my child to receive medical treatment. I consent that in the event of severe injury or illness the means of transportation may be ambulance at a cost to myself.*

Parent/Guardian Signature*

I declare that the information which I have provided on this form is complete and correct and that I will notify the program if any changes occur. I authorize the facilitator who is with my child to consent, where it is impractical to communicate with me, for my child to receive such medical or surgical treatment as may be deemed necessary. Clear

Date of Submission*

Date

ASSUMPTION OF RISK:

I/ we, the undersigned, are aware that:

(a) the Province of British Columbia has declared a State of Emergency as a result of the Covid 19 pandemic;

(b) the Provincial Health Officer has provided guidelines for the prevention and control of Covid 19, and ELEVATION OUTDOOR EXPERIENTIAL PROGRAMS ASSOCIATION (“Elevation”) is offering outdoor experiential programs to children, with rules and procedures in place to follow the provincial guidelines, however Elevation cannot and does not guarantee that the Participant will not come into contact with the Covid 19 virus as a result of participating in Elevation Programs;

(c) participating in the programs provided by Elevation involves inherent risks as a result of the interaction between participants, instructors, and other people, shared equipment, and excursions to public spaces, including the risk of exposure to the Covid 19 virus, and the risk of contracting and spreading the Covid 19 virus, and any related infections or complications;

(d) if Elevation has reason to believe that the Participant has been exposed to the Covid 19 virus, or is showing any symptoms of the Covid 19 virus, Elevation will not allow the Participant to continue participating in the Elevation programs, and will not be able to provide a refund, if applicable, for any paid spots in Elevation programs.

I/we are the parent(s) or legal guardian of the Participant. I/we are aware that participating in programs provided by Elevation involves an inherent risk of contracting and/or spreading the Covid 19 virus. I am also aware that the risks, dangers and hazards referred to above exist throughout the entire duration of the Elevation programs, and that the Participant may remain asymptomatic for an extended period of time after participating the Elevation programs, even though the Participant may have come into contact with the Covid 19 virus, and the Participant may be contagious.

I/ we confirm that Elevation has made no representations, warranties or other assurances with respect to the safety of participating in Elevation programs and has warned me of the risks associated with the Participant participating in Elevation programs. I/we freely accept and fully assume all such risks, dangers and hazards and the possibility of infection, illness, associated medical complications, personal injury, death, mandatory quarantine or self-isolation measures to the Participant and the Participant’s household or family members, as well as damage or loss, resulting therefrom.

I/we acknowledge and agree that this waiver will continue to apply even if the Provincial State of Emergency is lifted, and that Elevation reserves the right to refuse participation for anyone based on a suspected case of COVID-19 or suspected exposure to it, or if any Participant refused to follow safety protocols.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT

In consideration of the Participant being permitted to participate in Elevation programs, I/ we hereby agree as follows:

1. TO WAIVE ANY AND ALL CLAIMS that I/we have now or may in the future have against Elevation in connection with the Participants participation in Elevation programming, including Elevation’s directors, officers, employees, agents, and representatives (all of whom are hereinafter collectively referred to as the “RELEASEES”);

2. TO RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that I/we or the Participant may suffer as a result of the Participant participating in Elevation programs due to Covid 19, or due to any cause whatsoever, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE OCCUPIERS LIABILITY ACT, R.S.B.C. 1996, C.337, ON THE PART OF THE RELEASEES;

3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from and against any and all claims, actions, damages, liability and expenses in connection with loss of life, personal injury sustained or damages arising from the Participant participation in Elevation programs, including the loss of any registration fees, and to indemnify Elevation from and against any claims that the Participant may have, now or in the future, against Elevation as a result of the Participant participating in Elevation programs; and

4. This agreement shall be effective and binding upon my/our heirs, next of kin, executors, administrators, assigns and representatives in the event of my/our death or incapacity.

In entering into this Agreement, I/we am not relying upon any oral or written representations or statements made by the Releasees other than what is set forth in this Agreement.

I/WE HAVE READ AND UNDERSTAND THIS AGREEMENT AND I/WE ARE AWARE THAT BY SIGNING THIS AGREEMENT I/WE ARE WAIVING CERTAIN LEGAL RIGHTS WHICH I/WE OR MY/OUR HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE AGAINST THE RELEASEES.

This agreement must be completed in full, signed, dated and witnessed before participating in the program.

Name of Legal Guardian

First Name Last Name

Legal Guardian Signature

Clear

Name of Witness

First Name Last Name

Witness Signature

Clear

Date of Submission

Date

This program is brought to you, in part, by:

Get A Grip Application Package

Get a Grip 2022 Permission Form

Participants Medical Form

Medical History

COVID 19 RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT