LEAP TRAINING REQUIRED GUARDIAN FORM

LEAP TRAINING PARENT REQUIRED FORM

TEEN HEALTH INFO AND HOLD HARMLESS
The following is required for your teen's participation in the LEAP Youth Training.

If you haven't already, you will be receiving a call from a GAP team member to set-up a one-hour time prior to the training. The purpose of that call is to go over the same info in this form, as well as to answer any questions you might have. Your teen will also receive a call from a team member to set-up a seperate time by phone. The purpose of their call is to support them in being clear about what it is that the want to get out of the 4 days.
Teen's Name*

First NameLast Name
Teen's Birthdate*

MonthDayYear
Date
Parent 1/Guardian's Name*

First NameLast Name
Parent 1/Guardian's Email*
example@example.com
Parent 1/Guardian's Phone*
Please enter a valid phone number.
Parent 2/Guardian's Name

First NameLast Name
Parent 2/Guardian's Email
example@example.com
Parent 1/Guardian's Phone
Please enter a valid phone number.
Teen primarily resides with:
Teen's primary address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date your teen's LEAP Training Begins*

MonthDayYear
Date
City / Location of Your Training*

HEALTH ASSESSMENT
This part of the assessment is not intended to be used for purposes of screening. We do not and cannot screen our participants. Only you can decide what is right for your teen and the appropriateness of their participation. The information requested in this form and presented in the Course Outline is provided to assist you in doing that.

Please answer all of the following questions completely. Your answers will be kept confidential. The information requested here is to enable us to better support your teen in the Training. However, it is not possible for us to predict any participant’s experience. If during the Training, your teen finds themselves feeling uncomfortable to a degree that they think is excessive, we request that your teen report this immediately to the trainer or a team member.

If you have any question about whether or not your teen should participate at this time, please consult a professional.
Is your teen currently seeing a mental health professional, or have they seen one within the past 12 months?*

YesNo

You answered “yes” to question indicating that your teen is currently seeing a mental health professional or has been in the last year. We require that you discuss with your current or former therapist the advisability of your teen participating in the LEAP Youth Training at this time. You as the parent/guardian must sign the Therapy Personal Release below, verifying that you will have a conversation prior to the training.

We urge you to fully express to your therapist any concerns you may have, and listen closely to any concerns your therapist may have for your teen. We strongly recommend that you follow your therapist’s advice as to whether or not this is an appropriate time for your teen to take the Training. If your therapist requires more information, they are welcome to review this form and/or contact the GAP Awaken Director of Communications, Marla Neighbour, at 909.730.3888.

THERAPY PERSONAL RELEASE

I will talk with my teen's therapist, and asked their opinion about my teen's participation in the Training. My choice for my teen to participate in the Training at this time is made with the benefit of my therapist’s advice.

I am aware that by typing my first and last name below and submitting this form, it is representative of my signature.
Signature

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Name

First NameLast Name
Date

MonthDayYear
Date

Has your teen ever been incapacitated by severe depression, anxiety, or other mental crisis?*

YESNO
Please briefly describe*
Has your teen ever harmed themselves or become violent toward others?*

YESNO
Please briefly describe*
Is your teen currently under a doctor’s care?*

YESNO
Please briefly describe*

MEDICAL INFORMATION
Insurance / Medical Coverage
Policy Number
My teen has permission to take the following medication under supervision:
Aspirin*

YesNo
Tylenol*

YesNo
Advil*

YesNo
My teen is allergic to the following:
My teen is presently taking the following medication(s). Specify dosage, frequency, and time of day or any other important details.

EMERGENCY CONTACT
When neither parent/guardian can be reached, and/or in case of emergency, list one emergency contact. If parent(s)/guardian(s) and the emergency contact can not be reached, in case of your teen being injured or ill, the on-site medical person provided by the camp will make the best decision they see fit, which may or may not include taking your teen to the nearest medical facility for necessary treatment and/or medication.
EMERGENCY CONTACT*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*

PERMISSION TO TRAVEL
I give my permission for my teen to travel (if needed) by chartered bus, or personal vehicles driven by background checked and Live-Scanned volunteers to and from the Ropes Course (if not on campground site).
Signature*

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ROPES COURSE RELEASE
The outdoor portion of the training is held on a Ropes Course. The activities on this course are directed and supervised by qualified instructors and teens participating on the high portions are required to wear the safety harnesses provided. There are as with any outdoor activity risks involved. Understanding this I give my teen permission to participate.
Signature*

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HOLD HARMLESS
In this form, you will be asked to sign a standard release form, agreeing to assume full responsibility for your teen's participation in the LEAP Youth Training. If you choose not to sign the form, your teen may participate in the Training for a payment of an additional $300.00 to cover your liability insurance.

If you have any questions, you can contact Marla Neighbour, Director of Communications, at (909) 730-3888.
SECTION I: CONSENT TO PARTICIPATE
1. I acknowledge that I am fully and satisfactorily informed about the Training offered by GAP COMMUNITY and Sponsor and that my teen is freely and willingly participating in the training.
2. I understand that the training and all reference to the training includes not only the four days but also future related activities in which my teen may or may not choose to participate.
3. I understand the TRAINING is an experiential, philosophical, Christian education program that may or may not assist in personal growth. It is neither psychotherapy, nor medical therapy nor a substitute for either of these. GAP COMMUNITY trainers are not licensed psychiatrists or psychologists.
4. I understand that the TRAINING may involve physical contact such as hugging and if my teen does not consent to this they may object or tell the trainer before or at the time the contact occurs. I further understand that several of the processes in the TRAINING involve sharing which may evoke deep emotions, possible emotional stress, anxiety, tears or physical discomfort or exhaustion.
5. I do not have any doubts about my teen's mental health and/or emotional stability in regards to handling the rigors of the TRAINING. I have resolved any such doubts I may have had about the TRAINING by consulting others who are knowledgeable including but not limited to a physician, psychiatrist, psycho-therapist or psychologist. Such person(s) have no objections to my teen's participation in the TRAINING.
6. I understand that GAP COMMUNITY, Sponsor, their employees, staff and team members (“GAP COMMUNITY and Sponsor Team”) are here to assist me and are responsible only for presenting the TRAINING in an orderly manner. The GAP COMMUNITY and Sponsor Team are not my fiduciaries and I do not expect the TRAINING to be administered with the standard of care expected of trained mental health professionals. If my teen feels mental or physical discomfort or adverse effects during the TRAINING, I will request in advance that my teen inform a GAP COMMUNITY and Sponsor Team member immediately.
7. I understand that my teen is free to leave the TRAINING at any time or any reason. If during the TRAINING my teen feel the need for assistance from anyone, either professional or otherwise, they have my consent to contact and obtain such assistance.
SECTION II - INSURANCE DISCLAIMER
1. I understand that GAP COMMUNITY and Sponsor do not provide any insurance (neither medical, liability, professional nor incident) for my participation in the TRAINING. Thus, if I want insurance of any kind, it is my full responsibility to obtain such insurance.
SECTION III – RELEASE OF LIABILITY and WAIVER OF RIGHT TO SUE
1. Assumption Of Risk: I am fully aware that my teen participating in the TRAINING may contain risks of physical or psychological injury. I know and fully understand the scope, nature and extent of the risks involved in the TRAINING and activities contemplated by this Agreement. I voluntarily and freely incur and assume any and all such risks and dangers.
2. I hereby fully and forever discharge and release GAP COMMUNITY and Sponsor from any and all liability, claims, demands, actions and causes of action whatsoever arising out of any damages, both in law and in equity, in any way resulting from personal, physical, psychological or emotional injuries, distress or death arising from or in any way related to the TRAINING for my teen. This release from liability includes loss, damage or injury resulting from the negligence of GAP COMMUNITY and Sponsor from any other cause or causes.
3. I agree not to institute, initiate or assist the prosecution of any suit, claim or action at law or equity or otherwise against GAP COMMUNITY and Sponsor for damages which I or my heirs, executors, administrators, or assigns hereafter may have arising from or in any way related to the TRAINING. This release from liability includes loss, damage, or injury resulting from the negligence or GAP COMMUNITY and Sponsor from any other cause or causes.
4. Indemnity: I agree to indemnify and hold harmless GAP COMMUNITY and Sponsor from any and all losses, claims, actions or proceedings of any kind which may be initiated by me and/or any other person or organization on my behalf against GAP COMMUNITY and Sponsor. This indemnification includes reimbursement of all legal costs and reasonable attorney’s fees incurred by GAP COMMUNITY and Sponsor to defend any such actions.
5. Waiver of Punitive Damages: I understand and agree that I am waiving and forever abandoning any claims for punitive, or exemplary, incidental or consequential damages, against GAP COMMUNITY and Sponsor. I voluntarily choose to give up this right.
SECTION IV: ARBITRATION
1. Arbitration: I agree that any controversy claim again GAP COMMUNITY and Sponsor not released herein, arising out of or relating to my teen's participation in the TRAINING, shall be settled first by mediation between the parties then by arbitration in accordance with the rules of the American Arbitration Association, and not by lawsuit or resort to court process. I fully understand I am giving up my right to sue GAP COMMUNITY and Sponsor in a court of law or equity. This shall apply to all claims, including allegations that there have been wrongful acts or omissions by GAP COMMUNITY and Sponsor either intentionally or otherwise. The arbitrator’s decisions may be entered in any court having competent jurisdiction. By signing this I am agreeing that any issue or claim arising out of my teen's participation in the TRAINING shall be decided by neutral arbitration. I am giving up my right to trial by a jury or judge.
SECTION V: MISCELLANEOUS
1. Governing Law: I understand that this Agreement shall be construed and governed by the laws of the State of California, and that it cannot be modified unless in writing and signed by both parties.
2. Entire Agreement: I understand that this Agreement contains ALL the provisions, promises and agreements between the parties with regard to the release of GAP COMMUNITY and Sponsor. I acknowledge that there are no oral or written promises or agreements outside of this agreement regarding the release of GAP COMMUNITY and Sponsor.
3. Contract: I hereby expressly recognize that this Agreement is a contract I have released any and all claims against GAP COMMUNITY and Sponsor.
CONSENT

I have carefully read this agreement and understand its contents. I certify that I am 18 years of age or older and I sign this agreement on behalf of my teen and of my own free will.

For and in consideration of the mutual promises and agreements set forth above, and for my teen's voluntary participation in the GAP Community training, by signing my name below, I agree to this entire agreement and each of its individual sections.
Signature*

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Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

VERIFICATION
By clicking submit, I hereby acknowledge and attest that I have thoroughly and carefully read the information contained herein, that I understand it, that I have answered all the questions fully and truthfully, and that I take full responsibility for my participation in the LEAP Youth Training
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LEAP TRAINING PARENT REQUIRED FORM

HEALTH ASSESSMENT

PERSONAL RELEASE

MEDICAL INFORMATION

EMERGENCY CONTACT

PERMISSION TO TRAVEL

ROPES COURSE RELEASE

HOLD HARMLESS

SECTION I: CONSENT TO PARTICIPATE

SECTION II - INSURANCE DISCLAIMER

SECTION III – RELEASE OF LIABILITY and WAIVER OF RIGHT TO SUE

SECTION IV: ARBITRATION

SECTION V: MISCELLANEOUS

CONSENT

VERIFICATION