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Rsu5-rce.org

Participant Information and Agreement
Participant Name ___________________________________________________ Age___________ Home Phone___________________ Address__________________________________________ City___________________________________ State_________ Zip________ Email Address____________________________________________________________________________________________________ Outing/Trip Name___PORT Outdoors Winter Hut Trip to Flagstaff hut__________________________________ Trip Date_March 29-30
Emergency Contacts
In case of an emergency or illness, we will attempt to contact the following people in the order listed below: Parent/Guardian_____________________________________________________________ Home Phone_________________________ Work Phone___________________________________________ Cell Phone_______________________________________________ Parent/Guardian_________________________________________ Home Phone_____________________________________________ Work Phone____________________________________________ Cell Phone_______________________________________________ Alternate Emergency Contact _______________________________________Relationship_______________________________________ Phone (1)_________________________________ Phone (2)_________________________________ Medical Information
Physician______________________________________________________________ Phone____________________________________ Address_________________________________________________________________________________________________________ Insurance Carrier______________________________ ___________________________________________________________________ Policy #_____________________ _________________Group#_____________________________________________________________ Chronic or recurring illness/medical condition(s)__________________________________________________________________________ ________________________________________________________________________________________________________________ Allergies_________________________________________________________________________________________________________ Current Medications________________________________________________________________________________________________ Does your child carry emergency medications such as an epi-pen or inhaler? Special Needs/Limitations___________________________________________________________________________________________ ________________________________________________________________________________________________________________ Dietary Restrictions________________________________________________________________________________________________ Other information we should be aware of_______________________________________________________________________________ ________________________________________________________________________________________________________________ Over the Counter Medications
At the discretion and good judgment of The PORT teen center staff, student participants may receive the following over the counter medication in accordance with package directions: Ibuprofen (Advil), Acetaminophen (Tylenol), Diphenhydramine (Benadryl, anti-histamine), Hydrocortisone cream (itch-reliever), and Loperamide (Imodium AD, anti-diarrheal).
____I do ____I do not give permission for my son/daughter to receive the over the counter medications listed above.
Behavior Agreement
The PORT Outdoors aims to provide inclusive, healthy, fun, and chem-free outdoor recreation opportunities. The PORT Outdoors trips are a safe place for every person to learn about themselves, the world, and others in a safe, supportive, and tolerant environment. Bullying, hate speech, social exclusion, and harassment are not acceptable. The PORT Outdoors expects each participant to treat themselves, others, property, and the environment safely and respectfully. The PORT Outdoors teaches Leave No Trace conservation techniques to preserve out natural world. Drugs, alcohol, and tobacco are not permitted on any offerings. ___I have discussed the above behavior agreement with my son/daughter, and he/she agrees to abide by the expectations.
Liability Release
I hereby grant permission for the above named child to participate in the above named trip conducted by the PORT Outdoors. I agree to release, discharge, indemnify and hold the Town of Freeport, RSU5 Recreation & Community Education, the PORT Teen Center and their agents and employees harmless from any liability claims, demands, costs or damages arising out of said program activities which are sustained during participation. Permission is hereby granted for my child to receive emergency medical treatment, including transportation and hospitalization, if needed. I certify that my child is in good physical health and that there are no limits to his/her participation except as stated in writing above. I understand that any photographs taken during these programs may be used by the PORT, or RSU5-RCE, for promotional purposes. I have read this document carefully, and sign it voluntarily with full knowledge of its significance.
Parent/Guardian Signature_______________________________________ Date___________________________________ Participant Name_______________________________________________________________________________________

Source: http://www.rsu5-rce.org/wp-content/uploads/2014/02/Port-Outdoors-Participation-Agreement.pdf

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