High Risk Activity Release High Risk Activity Release Form InstructionsPlease 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/GuardianPlease select your Mentoring Coordinator(Required) Adrianna Kipp Alexis Gardner Alysha Vivian Ezra Loggin Jacqueline Sookermany High Risk Activity (Please type the name of the High Risk Activity)(Required) High Risk Activity Consent(Required) By checking this box, I agree to the terms listed below.I agree to give permission for my child/youth to participate in the following high risk activity (listed below), with his/her/their Big Brother/Big Sister/Mentor. I understand that if my child participates in this activity they are exposed to a higher level of uncertainty, danger, and hazards. If my child/youth is hurt, or does not heed the safety measures outlined above, I will not hold Big Brothers Big Sisters of Victoria Capital Region liable for any damages or injuries.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) MM slash DD slash YYYY MentorMentor Consent(Required) By clicking this box, and typing my name below I agree to follow the conditions and safety considerations listed in the High Risk Activity Release Form.Mentor Name(Required) First Last Mentor Email(Required) Date Mentor Signed(Required) MM slash DD slash YYYY Mentoring CoordinatorMentoring Coordinator Name(Required) First Last Mentoring Coordinator Email(Required) Date Mentoring Coordinator Signed(Required) MM slash DD slash YYYY
