High Risk Activity Release

High Risk Activity Release Form

Instructions

Please only fill out the appropriate section below (ex: Parents/Guardians, only fill out Parent/Guardian section). Once you have filled out your section select "Save and Continue Later" at the bottom of the form.

Parent/Guardian

Please select your Mentoring Coordinator(Required)

Alexis Gardner

Alysha Vivian

Julia Ross

Alexis Miedema

High Risk Activity (Please type the name of the High Risk Activity)(Required)

I have reviewed the following safety considerations with regards to the activity with my child's mentor (list safety considerations in the box below).(Required)

*Note: It is important to review with your child’s mentor all applicable safety considerations, including but not limited to: safety equipment (helmets, padding, life jackets, appropriate clothing/foot wear/gear), access to communication, available first aid. If the activity is on a boat, a plane or is offered by another organization do they have insurance, a license or operating membership. Will the mentor and child be monitored by a staff or representative of an organization; have they completed an orientation, are they able to assure compliance with the rules of the organization or activity? Example: If your child and their mentor are renting kayaks, does the rental company have their own insurance, safety, and orientation protocols? Have you reviewed this with the mentor? Does the mentor have an outlined route that they will travel on? Has the mentor provided a timeline for which the activity will take place, a communication plan, and an emergency response plan, should they not be back on time?

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email(Required)

Date Parent/Guardian Signed(Required)

Mentor

Mentor Name(Required)

First Last

Mentor Email(Required)

Date Mentor Signed(Required)

Mentoring Coordinator

Mentoring Coordinator Name(Required)

First Last

Mentoring Coordinator Email(Required)

Date Mentoring Coordinator Signed(Required)