Outdoor Adventure Estes Park! Calling All 6th Graders!

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1 Outdoor Adventure Estes Park! Calling All 6th Graders! Join us Wednesday thru Friday, October 3rd-5th for 3 days of fun and learning at the Estes Park Center YMCA of the Rockies. Legacy Academy has reserved the Pattie Hyde Barclay Reunion cabin for our lodging. Students will attend classes designed to meet Colorado State education standards, and relax with activities of their choice such as the Center s pool, our lodge, shooting some hoops, or creating crafts in the craft barn. When students were asked on a survey after last year s trip, What would you tell next year's 6th graders about Outdoor Education, students said: * Be ready for some fun! * That this trip will be educational and full of life long memories! * I would tell them that they are going to have an amazing time in Estes Park! Details: s: October 3, 4, 5th 2018 Cost: $ (includes transportation, lodging, classes, and all meals and snacks) Deposit: $60.00 nonrefundable deposit due by Wednesday, August 29th Final Payment(s): After the deposit of $60, a final payment of $140 is due by Thursday Sept. 27th, If you prefer to split the payment, 2 payments of $70 each need to be made by September 14th and September 27th. Need Volunteer hours? Each $10 put towards a student Scholarship Fund for Outdoor Education counts towards 1 hour of volunteer service. Forms Due: August 29th Parent Chaperones: Must have Legacy Background Check and will be accepted based on specific criteria. Staff Sponsors: Denise LeSage (denise.lesage@legacyk8.org) and Dana Henderson (dana.henderson@legacyk8.org) Please feel free to contact your child s Science teacher with any questions. Submit forms and payments to your child s Science teacher (Mrs. LeSage/Mrs. Henderson) and or the office. You may also pay by credit card using Square at the front office, please make sure to mark that it is for the 6th Grade Outdoor Education Trip.

2 YMCA of the Rockies Outdoor Education Student Liability Release By means of this agreement the undersigned individually, and on behalf of the participant child release, waive and discharge any and all claims against YMCA of the Rockies - Estes Park Center, Outdoor Education Department for any and all liability for any and all loss or damage caused by negligent acts or omissions of YMCA of the Rockies. School Student Name Phone Race Sex of Birth Address City State Zip Code To Parent or Guardian: Acknowledgement of risk, waiver, release and indemnification This permission form must be filled out completely and returned to your child s teacher in order for your child to attend activities at the YMCA of the Rockies. No child will be permitted to participate in activities at the YMCA of the Rockies without the complete and signed form. We, the Parents/Guardians of, individually and on behalf of the participant child, do hereby release the YMCA of the Rockies, Outdoor Education Instructors, Outdoor Education Department from any damages as a result of any sickness or injury during the duration of their Outdoor Education experience. We further understand and acknowledge that certain adventure activities, high ropes, walking on uneven trails, etc. have an increased risk of injury. Certain risks cannot be eliminated due to the Center s mountain setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be the cause of loss or damage to your property, accidental injury or illness, or in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about the inherent risks. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTANTD IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR THE CHILD PARTICIPANT S INJURY OR DEATH OR DAMAGE TO THE CHILD PARTICIPANT S PROPERTY THAT OCCURS WHILE PARTICIPATING IN OUTDOOR EDUCATION EXPERIENCES AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY THE CHILD PARTICIPANT S NEGLIGENT OR INTENTIONAL ACT OR OMISSION. Signature of Student Signature of Parent/Guardian #1 Signature of Parent/Guardian #2

3 Legacy Academy 1975 Legacy Circle Elizabeth, CO (303) YOUTH CONSENT AND RELEASE To be completed by parent or guardian if Participant is under 18 years of age, otherwise to be completed by the Participant. Both parental signatures on the medical release are required and must be notarized if Participant is under 18 years of age unless otherwise directed. Parent or Guardian Participant Organization Legacy Academy (Sponsor) Name (herein parent or guardian ) Name (herein Participant ) / / Name (herein parent or guardian ) of birth (mm/dd/year) Gender (M/F) LA Team Leader (herein Agent) Release of Liability By signing this form I acknowledge that participating in Legacy Academy activities is a privilege. I understand that there are certain risks of physical injury or illness associated with these activities. In addition, I understand that there may be other risks associated with these activities of which I may not be presently aware. In consideration of your accepting me or my child for participation in the above named program, I hereby waive and release any and all rights and claims for damages that I as parent, or my child may have against Legacy Academy and its affiliates, volunteers, agents, employees, representatives, successors and assigns for any and all injuries suffered by me or my child that arise out of the subject program, sponsored by Legacy Academy. I further agree that in the event that my child or other related person should make any claim in the future against Legacy Academy, I will personally indemnify, defend and hold harmless Legacy Academy and its affiliates, agents, employees, representatives, volunteers, successors and assigns against any and all loss and damage, including attorney s fees, arising directly or indirectly from my child s actions. Consent to Treatment (to be completed regardless of age of Participant) By signing this form I,, as (circle one) the Parent / the Guardian, do hereby authorize the abovereferenced Agent, acting as the Participant s agent, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or other emergency medical treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of any licensed physician or surgeon; or to consent to an X- ray examination, anesthetic, dental or surgical diagnosis or emergency treatment to be rendered to the Participant by any licensed dentist. It is understood that this authorization is given in advance of any condition which might occur necessitating treatment, but it is given to provide authority and power on the part of the Agent to give specific consent to any such examination, anesthetic, diagnosis, treatment or hospital care which the aforementioned surgeon, physician and/or dentist, in the exercise of his/her best judgment, may deem advisable. It is also understood that since licensing standards vary between states and nations, the aforementioned surgeon, physician and/or dentist by meet only those qualifications required for licensing in the state or nation where he/she practices. I hereby authorize any hospital which has provided treatment to the Participant to surrender physical custody of the Participant to the Agent upon completion of treatment. I hereby agree to pay all costs of medical and dental care incurred by the Agent on behalf of the Participant if said costs are in excess of those covered by any insurance provided to the Participant by the Sponsor Organization. Effective dates: August May 2019 Signature of Parent/Guardian - Required Signature of Parent/Guardian - Required Emergency Information (must be completed regardless of age) Insurance Company (other than provided by Legacy Academy) Company Name: Policy #: Insured s Name: Group Name: Group #: Insured s S.S. #: In case Parent/Guardian is to be notified: Address: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Alt Phone: ( ) In case Parent/Guardian cannot be reached, notify: Name: Relationship to Participant: Home phone: ( ) Work Phone: ( ) Alt Phone ( ) Please list all allergies, medications, illnesses, special needs or disabilities of the Participant: Participant s blood type: (not required)

4 Legacy Academy Over-the-Counter Medications Permission Name of Student Grade Please initial or check Yes or No on each line, then sign below. Yes No 1. Acetaminophen Regular Strength (Tylenol or Generic Substitute) (Only 2 doses will be given per day. If the problem persists, or child has a fever over 101, parent will be contacted to take the child home.) 2. Polymyxin B Sulfate-Bacitracin Zinc-Neomycin Sulfate Ointment (Neosporin Ointment or Generic Substitute) 3. Mentholated Throat or Cough Drop or Generic Substitute (If fever present, or pain or cough persists, you will be notified to take child home.) 4. Benadryl Cream, Calamine/ Caladryl Lotion or Generic Substitute (If rash is present, parent will be notified to take child home.) 5. Burn Gel, Aloe Vera Lotion, Lidocaine1% or Generic Substitute 6. Calcium Carbonate (Tums or Generic Substitute) or mint. (If vomiting occurs, child will be sent home.) 7. Ibuprofen (Motrin, Advil, or Generic Substitute) (Parent needs to supply if taken on a frequent basis.) 8. Saline Eye Drops (Liquid Tears or Generic Substitute) 9. Hand Lotion, Vaseline or Lip Balm, or Sunscreen (Parent to supply Sunscreen) These common over-the-counter medications and appropriate dosages have been approved by a local physician and we have his/her permission to administer them during the school year to those children whose parents/guardian approve. No medication will be given unless absolutely necessary and other avenues have proven ineffective for relief. It is absolutely necessary to have your permission before dispensing/ administering any medication to your child while he/she is at school. If this form is not returned to school, your child will not be given any medications. Please indicate if your child has an allergy to a specific generic or name-brand drug. If you have any question or concerns, please feel free to contact the school health aide or office staff at the school your child attends. I have carefully read the information above and hereby authorize the school nurse or designee to administer the above medications, only as approved, during the current school year. Additional Comments: Signature of Parent/Guardian :

5 LEGACY ACADEMY PERMISSION FOR MEDICATION Full Name of Student: Medication: Grade: Dosage: Purpose of Medication: Time of day medication is to be given: Possible side effects: Anticipated number of days it needs to be given at school: Permission for student to carry medication: **Medication must come in its original container, labeled with the student s name and dosage by physician.** Signature of Physician It is understood that they medication is administered solely at the request of and as an accommodation to the undersigned parent or guardian. In consideration of the acceptance of the request to perform this service by the school nurse or other designee employed by Legacy Academy, the undersigned parent or guardian hereby agrees to release Legacy Academy and its personnel from any legal claim which they now have or may hereafter have arising out of side effects or other medical consequences of the medication. I hereby give my permission for to take the above prescription at school as ordered. I understand that it is my responsibility to furnish this medication. Signature of Parent or Guardian The prescription medication is to be brought to school in a container appropriately labeled by the pharmacy, or physician, state the name of the medication and the dosage LEGACY CIRCLE ELIZABETH, CO PHONE (303) FAX (303)

6 Packing List Our classes are conducted outdoors in the rain or shine, and it is ESSENTIAL that each student comes prepared for all types of weather. We realize that it may be inconvenient to purchase the listed items, so we encourage you to borrow items that you do not own. We want your child to stay warm and dry while they re on this trip. The weather in the mountains can change very quickly. Being prepared for any type of weather ensures a happy experience. There are many times when classes are conducted through rain storms and snow! These items listed are necessary for all seasons. Please label all your child s belongings, this helps if items are lost. Essentials: Day pack or book bag Warm Coat or Jacket Gloves/Mittens Shade Hat Sweater or sweatshirts Sturdy shoes or hiking boots(recommend water proof for rain/snow) Extra pair of shoes-athletic Rainwear-Jacket, pants or poncho/disposable rain jackets(no trashbags please) Extra socks Change of clothes Sleeping Attire Long underwear Water bottle- 2 liter bottles are great! Personal toiletries Sunglasses Sunscreen Pencil and journal Optional: Flashlight Swimsuit (if swimming) Ladies: 1 piece swim suit or tankini whose top is no higher than your belly button. You cannot wear cotton t-shirts or shorts Camera (disposable! Digital is NOT recommended (damage or loss can happen) Book Money for crafts (no more than $20, sealed in a baggie with your name in sharpie) THIS WILL BE GIVEN TO YOUR SECTION LEADER DO NOT BRING Knives/weapons Matches ipad, ipod, PSP(handheld game systems) Cell phones Candy and junk food Linens (YMCA provides towels and linens)