Leaders in Action Application Package

Leaders in Action program dates typically run on Mondays and Wednesday, with occasional weekend dates for snowboarding or outdoor climbing/hiking, from the months of September to June.

Full Name of Applicant*

First NameLast Name

Age of applicant as of September 1st - *YOUTH MUST BE AT LEAST 15 YEARS OLD BY SEPT 1st TO APPLY FOR THIS PROGRAM**

How did you hear about us?*

Place of Residence as of September 1st*

Street Address

Street Address Line 2

CityState / 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:

Have you participated in an Elevation Outdoors program before? If yes, please write below which ones and when you participated. If NO, please use the space below to inform us of your experience with hiking, rock climbing, snowboarding, and mountain biking, and any other relevant outdoor recreation experience. Note: level of experience is for our knowledge and will not impact your consideration for acceptance into the program.*

In your own words please define what leadership means to you, and why you are interested in participating in this program?*

In your own words what are you hoping to gain through your participation in this program?*

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 ($3,000/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 on the web page).

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's Email Address

example@example.com

Youth's Email Address

example@example.com

I give permission to Elevation Outdoors staff to reach out to my youth with program updates via email throughout the course of the program.

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.*

Funding to help us make this program possible is generously provided by MEC

FOR YOUTH: Below are the expectations of all participates in the Leaders in Action program (by selecting each option, you are agreeing to meet that program expectation):

1. You are able to commit to attending, on average, 2 sessions per week from September - June.2. You are willing to share your knowledge and passion with younger participants in our other programs to help develop your leadership skills.3. You are willing to put in time outside of our scheduled program days to assist in fundraising events to pay for the end of year trip.4. You will participate to the fullest of your ability in all activities throughout the duration of the program.5. Volunteering - As part of the program you will be asked to contribute a minimum of 30 hours of volunteering with our other programs, or in the community, to help you meet your high school graduation requirements. These hours can replace other program days to allow for balance in your schedule.6. You agree to no use of drugs or alcohol or show up under the influence during any/all program related activities.

Participants Full Name*

First NameLast Name

Please Read and Sign - Participants Signature:*

I have read the above letter and understand the inherent risks in the activity of snowboarding, hiking, climbing and mountain biking, as well as the risks of participating in the program. I still want to participate with this in mind.

FOR PARENT/LEGAL GUARDIAN (please read the following):

Elevation Outdoors is running our Leaders in Action program over the months of September to June for youth in the Kelowna area. The program involves teaching young people to snowboard, rock climb, hike, and mountain bike. It also involves reflecting upon this experience and using it as a metaphor for life experiences and learning. This letter is informing you of the inherent risks in these activities.

Snowboarding:

Injury to participants is always a possibility when taking part in this sport. When learning to snowboard participants tend to fall frequently, putting their body, especially their wrists and arms, at risk of injury. Other risks involved with the activity include other individuals on the mountain who are not involved in the program. It is a possibility that a participant could be injured from other skiers or snowboarders who are wreckless or out of control, thus impacting on someone in their path. While unlikely, there is a potential for life threatening injuries or death related to snowboarding. Participants will be supervised at all times when on the mountain, and elementary terrain park use will not be permitted unless all the relevant skills are demonstrated by each participant beforehand.

Hiking and other outdoor activities:

DEFINITIONS: In this Release Agreement the term "Wilderness Activities” shall include all activities, events or services provided, arranged, organized, sponsored or authorized by the Releasees including, but not limited to: hiking; backpacking; wildlife viewing; back country travel; orientational and instructional courses, seminars and sessions; accommodation; transport to and from the trail head or marshalling areas; and all other activities, events and services in any way connected with or related to these activities.

ASSUMPTION OF RISKS: I am aware that participation in Wilderness Activities involves many risks, dangers and hazards including, but not limited to: travel on extreme terrain, particularly high, exposed ridge tops, steep pitches, or where the trail or route is less defined and therefore rough or unstable; travel in areas where fallen timber, shrubbery, branches, rocks, roots or other obstacles or hazards may impede or hinder travel; travel on or through boulder fields, avalanche and landslide paths, snow fields and glaciers; travel across or beside creeks, streams, rivers, ponds and lakes; encounters with domestic and wild animals, sudden and unexpected changes or variations in the hiking terrain; collisions with motor vehicles and natural or man-made objects; miscellaneous health problems related to over-exposure to the sun, insect bites, fatigue, stress, dehydration, exertion, high altitude, and lack of fitness. Participants may become lost or separated from their guide or party. Communication in the alpine or backcountry terrain is difficult and in the event of an accident, rescue and medical treatment may not be immediately available. Alpine and back country weather conditions may be extreme and can change rapidly and without warning. I am also aware that a further risk, danger and hazard of Wilderness Activities is negligence, inattention, or inexperience of other persons in the party and NEGLIGENCE ON THE PART OF THE RELEASEES, INCLUDING THE FAILURE ON THE PART OF THE RELEASEES AND THE PROVINCE TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS OF WILDERNESS ACTIVITIES REFERRED TO ABOVE.

I AM AWARE OF THE RISKS, DANGERS AND HAZARDS ASSOCIATED WITH WILDERNESS ACTIVITIES AND I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS, DANGERS AND HAZARDS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE OR LOSS RESULTING THEREFROM.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT: In consideration of the RELEASEES agreeing to my participation in the Wilderness Activities and permitting my use of their services, equipment and other facilities, and for other good and valuable consideration, the receipt and sufficiency of which is acknowledged, I hereby agree as follows:

1. TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the RELEASEES AND TO RELEASE THE RELEASEES from any and all liability for any loss, damage, expense or injury, including death, that I may suffer or that my next of kin may suffer, as a result of my participation in the Wilderness Activities, 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, ON THE PART OF THE RELEASEES, AND FURTHER INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS OF PARTICIPATING IN THE WILDERNESS ACTIVITIES REFERRED TO ABOVE;

2. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES for any and all liability for any property damage, loss or personal injury to any third party resulting from my participation in the Wilderness Activities;

3. This Release Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives, in the event of my death or incapacity;

4. This Release Agreement and any rights, duties and obligations as between the parties to this Release Agreement shall be governed by and interpreted solely in accordance with the laws of the province where the Wilderness Activities take place and no other jurisdiction; and

5. Any litigation involving the parties to this Release Agreement shall be brought solely within the province where the Wilderness Activities take place and shall be within the exclusive jurisdiction of the Courts of that province.

In entering into this Release Agreement I am not relying on any oral or written representations or statements made by the Releasees with respect to the safety of participating in the Wilderness Activities, other than what is set forth in this Release Agreement. I CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS RELEASE AGREEMENT PRIOR TO SIGNING IT, AND I AM AWARE THAT BY SIGNING THIS RELEASE AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATIVES MAY HAVE AGAINST THE RELEASEES.

Climbing:

Climbing days 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. 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 the 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 activitiesWe 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.

Mountain Biking:

Our mountain biking days will be using various terrain within the Okanagan valley, including cross country and downhill mountain biking. The program also involves reflecting upon these experiences and using it as a metaphor for life experiences and learning. The participants will go to Big White for downhill riding during the program, dates are to be determined. This letter is to inform you of the program and the expressed interest, and also of the inherent risks in the activity of mountain biking.

On my behalf, and on the behalf of any minor children participating in these activities, for whom I am legally responsible, I agree to the following:

ASSUMPTION OF RISKS: I am aware and understand that MOUNTAIN BIKING activities involve many risks, dangers and hazards, including but not limited to the following: I acknowledge and accept that mountain biking involves risks, dangers and hazards in addition to those normally associated with bicycle riding and that injuries are a common and expected part of mountain biking. The Live to Ride program may take place on steep and rugged terrain and will expose the rider to many risks, dangers and hazards. The terrain may be un‐inspected, uncontrolled and unsafe do to constantly changing conditions. The inherent risks, hazards and dangers include but are not limited to the following: collision with other riders, vehicles, bicycles, trees, tree stumps, tree wells or other objects; fences and other man made structures; mechanical failure of equipment; rapid an uncontrolled acceleration on hills and inclines; changing weather conditions; unsafe terrain including steep or slippery sections, cliffs, rocks, holes, or crevices; extreme variation in cycling terrain; encounters with domestic and non domestic animals; falling or being thrown off the mountain bike; negligence on the part of there leases – including the failure to protect the participant from the risk, dangers and hazards of mountain biking or to predict the whether the terrain is safe for mountain biking; negligence of other riders. I understand and acknowledge that no amount of caution, experience and instruction can eliminate all of the risks involved and I freely assume all such risks, dangers and hazards and the possibility of personal injury, death, property damage and damages or loss resulting therefrom. I understand and acknowledge that no amount of caution, experience and instruction can eliminate all of the risks involved and I freely assume all such risks, dangers and hazards and the possibility of personal injury, death, property damage and damages or loss resulting therefrom. Elevation is 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. Please be assured that all appropriate safety measures and risk management practices will be exercised while the program is being delivered. Helmets are mandatory. Body armour will also be worn on the downhill days. Participants will be supervised during all bike trips, and ‘black’ or most difficult runs will not be utilized unless appropriate skill has been demonstrated beforehand.

Elevation is 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. Please be assured that all appropriate safety measures and risk management practices will be exercised while the programs are being delivered. 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 and agree to the terms and conditions above:*

Parent/Guardians Full Name*

First NameLast Name

Please Read and Sign - Parent/Guardians Signature*

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

Please Read and Sign - Participants Signature*

I have read the above letter and understand the inherent risks in the activity of snowboarding, 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

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 - leave blank if no.

Area CodePhone Number

Input Todays Date*

Date

Participants Name*

First NameLast Name

Participants Date of Birth*

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

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?*

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*

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*

Date

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

Leaders in Action: Application Form

Participant Expectations and Permission Form

LIA Waivers

Participant Medical Form

Participant Medical History