Community Advocacy and Mentorship Program s (CAMP) Life Skills Retreat

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Nathan Reed
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1 Community Advocacy and Mentorship Program s (CAMP) Life Skills Retreat WHAT IS THIS? The Pediatric AIDS Coalition (PAC) at UCLA puts on a Life Skills Retreat for students around the country to participate in a weekend long event that is catered to provide a space for young adults to grow and learn new skills that will help them in all aspects of their life. This retreat is coordinated and ran by current UCLA students who are apart of CAMP. We will also have at least one therapist during the weekend where students can schedule a one-on-one time if they would like. The goal of this retreat is to address every aspect of the student s life now and their future endeavors. This includes but is not limited to; mental/physical health, money management, college applications, preparing for job interviews, grants/scholarships, HIV 101 and more. EXPECTATIONS: CAMP s Life Skills retreat is designed so that students not only have a fun weekend but also have the opportunity to gain knowledge and advice on the many challenges students will face as they become a young adult. We are going to have a blast, but we are also going to have some very serious moments. CAMP has set forth expectations to ensure the safety and well-being of the student, which will allow them to get the most of Life Skills as possible. We expect everyone to respect the privacy of the cabins, use proper language, and treat everyone with respect. The use or possession of weapons, drugs, or alcohol are strictly prohibited at all times. Individual and group activities will provide a time for introspection and personal growth. This is a time for the students to focus on themselves. WHERE: Pali Mountain Retreat Center in Running California Highway 18, Running Springs, CA WHEN: Morning of February 18 to mid-day of the 20th

2 HOW? FILL OUT THIS INVITATION AND SEND IT BACK to and you may be eligible to attend this retreat! Please fill out the entirety of this form. Attached to this packet is a SURVEY, 3 WAIVERS (MEDIA WAIVER, LIFE SKILLS WAIVER, ANGEL FLIGHT WAIVER), AND ANGEL FLIGHT INFORMATION. *To send this document back, you can open it up as a word document and then write it in and send the updated one. Or you can send all of the information in an . CONTACT INFORMATION: If you have any questions, regarding the waivers or the retreat, please feel free to reach out to any of the following people on PAC. Director of Family Relations: Sarah Denison-Johnston pac.family.ucla@gmail.com Phone: (510) Co-Director of Life Skills Retreat: Marcela Gamino mgamino@g.ucla.edu Phone: (661) Co-Director of Life Skills Retreat: Kelyn Clark kelynjclark@gmail.com Phone: (253)

3 SURVEY 1. What are you expecting from Life Skills Retreat? 2. What are the most important skills for you now and in the future? 3. Is the college application process relevant for you? 4. Did you attend Life Skills Retreat last year? 5. If you did, what did you like about it? What could be improved? 5. Will you be able to commit to attending Life Skills for the entirety of the weekend (February 18-20)? If you cannot, please explain your time conflict. 5. Do you have any animal/pet allergies? 6. Do you have any food allergies?

4 *Some members of our media team will join us for the retreat, and attached is a consent form for them to be able to take pictures and videos at the retreat. Media Consent and Release Form Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the Pediatric AIDS Coalition at UCLA, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice; (b) Permission to use my name; and (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness. This consent is given in perpetuity, and does not require prior approval by me. Name: Signature: Address: Date: The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child. Signature of Parent or Legal Guardian: Print Name: The following is required if the consent form has to be read to the parent/legal guardian: I certify that I have read this consent form in full to the parent/legal guardian whose signature appears above. Date Signature of Organizational Representative

5 Name of Participant: LIFE SKILLS RETREAT 2016 Waiver of Liability, Assumption of Risk and Indemnity Agreement In consideration of being permitted to participate in way in Like Skills Retreat hereinafter called The Activity, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue the Pediatric Aids Coalition: Community Advocacy Mentorship Program (CAMP), its volunteers from liability from any and all claims including negligence of the Pediatric AIDS Coalition and its volunteers, resulting in personal injury, accidents or illness (including death), and property loss arising from, but not limited to, participation in The Activity. Signature of Parent/Guardian of Minor Date Signature of Participant Date Participation in The Activity carries with it certain inherit risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but risks range from 1) minor injuries such as scratches, bruises, and sprains2) major injuries such as eye injury, loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. Indemnification and Hold Harmless I also agree to INDEMNIFY AND HOLD the Pediatric AIDS Coalition HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney s fee brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred. I have read this waiver of Liability, assumption of risk and indemnity agreement, fully understand its terms and I understand I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. Signature of Parent/Guardian of Minor Date Signature of Participant Date

6 Transportation is provided for all campers. If you live outside the Los Angeles area we may be able to fly you in for free courtesy of Angel Flights West. This non-profit organization provides free flights in small private air crafts. In this portion of the application please read and complete the following: 1. Camper Request Form 2. Angel Flight Introduction Letter 3. Angel Flights Waiver of Liability 4. Medical Release form (only required for passengers with a known medical conditions) CAMP Camper Request Form Camper Name: DOB: Weight: * Street: City, State, Zip: Cell #: Home #: Other Phone #: Parent/ Guardian Names (circle one): Parent/ Guardian s(s): Please let us know if this is the camper s Medical Condition: Home Airport: Leave blank if you are unsure Special Needs: (such as ADHD, Hearing Impaired, Autism spectrum, Mobility Issues, etc.) *It is important that this weight is accurate because certain air crafts can only carry a certain amount of weight. Your weight will not prevent you from flying, but will provide Angel Flights West the information needed to find an appropriate aircraft for your needs.

Math + Leadership Camp Rancho Minerva Middle School July 11-22, Registration Form

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