Camp Cedar Springs Informed Consent Form

Camp Cedar Springs Outdoor Education/Overnight Experience Informed Consent

For Office Use Only:

Teacher     Living Group

Northshore School District

Student Name     Pupil ID Number

Name of School     Dates Attending

Detailed information provided at Parent Information Night held on

Brief Description of Activities & Transportation

✓ Transportation provided by district school bus

✓ Shelter Building, Survival, GPS and Art classes are instructed by NSD staff

✓ Rock Climbing, Range Archery, Fire Building, Student Forestry, Stream Life and Northwest Wildlife classes are instructed by Camp Cedar Springs staff. Class descriptions can be found at cedarspringscamp.net

Although the Northshore School District (NSD) attempts to ensure the safety of all involved in school activities, participation in an outdoor/overnight experience has inherent risks. Some activities, such as archery and use of the rock climbing wall, have higher risks than others, and could result in serious physical injury or death. Careful consideration should be given to the perils associated with camp activities before making the decision to participate.

In the case of serious medical emergency, 911 will be called to evaluate your child and/or the child will be transported to the nearest hospital for evaluation and treatment. Parents/guardians will be notified immediately. For non-urgent problems, the camp nurse will consult with the parents. Please provide a phone number (reverse side) where someone can be reached during this field trip.

Parent/Guardian Consent:

I understand this is a supplemental educational experience and my child is not required to participate. As the parent/guardian of the above named student, I have read the information provided and am fully aware there are dangers and risks inherent to participating in the activities named above.

I authorize qualified emergency medical professionals to examine and in the event of injury or serious illness, administer emergency care to the above named student. I understand every effort will be made to contact me to explain the nature of the problem prior to any involved treatment.

I have provided insurance and health information on the reverse side of this form.

In the event it becomes necessary for the school district staff to obtain emergency care for my child, neither staff nor the school district assumes financial liability for expenses incurred because of an accident, injury, illness and/or unforeseen circumstance. I understand NSD does not carry medical/injury insurance for my child and that I am responsible for any medical bills that may be incurred due to an accident, injury or illness of my child while at Camp Cedar Springs.

In consideration of the opportunity for my child to participate at Camp Cedar Springs I agree to defend, indemnify and hold harmless the Northshore School District, it’s officials, employees and volunteers from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or in connection with this activity, except for injuries and damages caused by the sole negligence of the district.

Print Parent/Guardian Name

Optional accident/injury insurance information is available on the district website, school office or can be sent home upon request.

To be completed by parent/guardian

In Case of Emergency

Student Name     Birthdate

Parent/Guardian 1st Contact     Parent Phone

Alternate Contact     Alternate Phone

Healthcare Provider Name     HCP Phone

Insurance Company     Subscriber Name

Subscriber Birth Date     Policy #     Group #

Insurance Address     Insurance Phone

I understand NSD does not carry accident/injury insurance for my child and that I am responsible for any medical bills that may be incurred due to an accident, injury or illness of my child while at Camp Cedar Springs.

My child has accident/injury insurance for medical expenses that may be incurred from the results of a camp activity.

My child does not have accident/injury coverage for an activity of this nature. I would like information on optional accident insurance.

Student Health and/or Medication Alert (Confidential)

My child has no known medical or physical condition which could interfere with his/her safety in this activity.

My child has a specific issue/condition that may affect participation or other conditions such as bed-wetting, sleep walking, allergies, special diet concerns, etc. Please list:

I understand NO medication is to be included in my child’s luggage

My child will bring “over the counter” or prescription medication on this field trip, other than what they normally take during the school day.

• All medication must be labeled in the original container with the student’s name on it

• Any medication not authorized by your physician cannot and will not be administered

• If bringing medication:

I have completed the form “Authorization for Medication” for Cedar Springs and it has been reviewed, signed and returned by the healthcare provider

My child has a Life Threatening Condition (e.g. severe bee/food allergies, severe asthma, seizures, diabetes, etc.). Describe (school will attach emergency plan)

Print Parent/Guardian Name