Take a Hike Application Package

Take a Hike Application Package

Please fill out all sections below
Application Form

*Youth must be at least 12 years old by start of program to apply.
Full name of applicant*

First NameLast Name
Age of applicant as of April 1 (the year of program applying for)*
Applicant's Pronouns (select those that apply):*

She/HerHe/HimThey/ThemPrefer Not to AnswerOther
Would you also like to apply for our Get a Grip climbing program (Dates: Tuesday and Thursday evenings in May and 2 Saturdays at end of May/beginning of June for full day outdoor climbs. *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*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you identify as a member of 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 hiker?*
If you responded 'no' the previous question, please tell us how many days' experience you have had and how long ago?
In your own words please explain why you would like to participate in our Take a Hike program.*
Can you be available every Tuesday and Thursday evening in the month of April for hikes?*
Please list any known conflicts with these days:*
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 ($250/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 requirement 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

Cancelof
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).
Guardian's 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.
Take a Hike Permission Form

Please read all the information below - you will be sent a version of the waiver below that you can fill out upon completing this application.
Guardian Full Name*

First NameLast Name
Signature of Guardian*

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

Clear
I have read the above letter and understand the inherent risks in the activity of hiking, as well as the risks of participating in the program. I still want to participate with this in mind.
Photo and Video Release - Parent/Guardian Signature

Clear
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.
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 CodePhone Number
Date

MonthDayYear
Date
Participants Medical Form

Please fill out all the requested information
Participants Name*

First NameLast Name
Participants Date of Birth*

MonthDayYear
Date
Participants BC Care Card Number*
Please provide the correct care card number
Parent/Guardians Name*

First NameLast Name
Parent/Guardians Phone number - Provide preferred contact number*

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

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

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

Area CodePhone Number
Medical History
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.
Does your child suffer from any of the following?*

NonePhobiasEpilepsyDiabetesBleeding DisordersHeart ConditionsMigranes/HeadachesSeeing DisordersHearing DisordersKnee/Ankle/Joint ProblemsConcussion (current or historic)
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.
Please select any of the following non-prescription medications you give permission for your child to receive if needed.*

Advil/Tylenol - pain/feverCold/Flu TabletsAntihistamine - bites/stings/allergiesNone
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*

Clear
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.
Date of Submission*

MonthDayYear
Date
This program is brought to you, in part, by:
Should be Empty:

Take a Hike Application Package

Take a Hike Permission Form

Participants Medical Form

Medical History