TEEN WILDERNESS ADVENTURES - Appalachian Mountain Club

TEEN WILDERNESS ADVENTURES
GENERAL INFORMATION
Welcome to the Appalachian Mountain Club’s Teen Wilderness Adventures! We have an exciting summer of
wilderness exploration, fun, and adventure planned. Enclosed in this packet you’ll find an abundance of
information and several forms. Please read through everything carefully. After reviewing all of the enclosed
materials, please call us with unanswered questions (603-466-2727). We’re looking forward to seeing you this
summer!
Our Mission: The mission of the Appalachian Mountain Club’s Teen Wilderness Adventures program is to foster
an appreciation for the environment, develop self-esteem, instill a spirit of adventure and promote teamwork,
friendships, and a sense of community through significant wilderness experiences.
Our Staff: The AMC's professional instructors are dedicated, energetic, and talented leaders experienced in
working with youth. All our instructors are trained and/or certified in wilderness medicine, water safety, Leave
No Trace principles, and have strong backcountry skills and ethics. They come from a wide variety of backgrounds
and life experiences and are committed to providing youth with a fun and educational experience in the outdoors
while maximizing the safety of all participants. At least two instructors, except in emergencies, will be with the
group for the entire trip. During a white water or mountain biking section, one or two instructors from Great Glen
Trails Outdoor Center (accredited by the American Canoe Association) will join them.
Our Expectations: We don’t require any prior backcountry experience to take part in most of our adventures,
although experienced teens still find them quite rewarding. What we do expect is a desire to try new things and
face new challenges as well as a willingness to cooperate with the group. Participants are expected to support each
other through challenges and share camp chores with the help and guidance of the instructors. Enthusiasm,
commitment, and a positive attitude will make this trip an adventure of a lifetime!
Getting in Shape: Participants do not have to be super athletes to enjoy any of the activities, but they will have a
more comfortable experience if they are prepared. We recommend a simple routine of regular exercise starting at
least a month before the trip. At minimum, work towards a half hour of aerobic activity at least three times a week.
Wear hiking boots as much as possible to break them in, walk whenever possible, and even take a few hikes with a
full backpack on to get used to the feel of carrying that extra weight. The instructors attempt to plan the itinerary
to suit the experience of the group, but the physical preparation of participants will help them and the group when
the trail gets a bit challenging.
Food: Participants eat three full meals a day, including plenty of snacks. We provide fresh food, probably similar to
what is eaten at home, although we might ask participants to try something new. Favorite meals include pastas,
burritos, stir-fry, hamburgers, bagels and cream cheese or peanut butter and jelly, dry and hot cereal, cookies,
granola, fruit, and hot chocolate for chilly evenings and mornings. We easily accommodate most dietary
restrictions; let us know in advance so we can plan accordingly. All the participants help prepare and clean up
after meals. They learn to use a camp stove and perhaps to make some new creations to impress family at home!
Mail: Due to the backcountry nature of these adventures, mail can only be picked up during the short time the
group transitions between activities at Pinkham Notch Visitor Center. If you would like to send your child mail,
please only do so if he or she is on a trip longer than a week, as the chances of receiving it in a shorter time are
small. Use the following address:
AMC- Teen Wilderness Adventures
Trip Name or Number
insert son’s or daughter’s name
PO Box 298, Rt. 16, Gorham, NH 03581
Money: Participants will not need any money during the trip. On trips of more than one activity, we might make a
quick stop at a gas station between sections. Please limit the money you bring to $20. The Trading Post at Pinkham
Notch Visitor Center has outdoor gear and souvenirs, and can be visited before or after the trip.
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Equipment and Clothing: We’ve included a detailed Equipment Checklist for participants in this packet. Limited
storage is available during the trip. If the trip includes more than one activity, the group will either return to
Pinkham Notch for a brief time to replace or exchange clothing and gear or their extra bags will be brought to them
in the field between activities. We can store items that might be needed for one activity but not another. For
example, we can store a pair of hiking boots once the backpacking segment is complete and the paddling portion is
about to start. We can also store a separate bag with clean clothes for the ride home.
Tents: The AMC provides two, three, and four-person backpacking tents. Boys and girls never share tents, a policy
strictly enforced by instructors. On occasions that the group might sleep together under a large tarp or in a
backcountry shelter, the instructors would ensure privacy for changing and an appropriate sleeping arrangement.
Transportation: During the trip, participants will be transported to and from trailheads, paddling locations, and
other activity areas in 12-passenger vans driven by the instructors and other support personnel. All van drivers
have gone through D.O.T. driver training and have had their driving records checked. We spend as little time as
possible driving between activities to maximize our time in the wilderness; most rides are 20 minutes- 1 hour; 3
hours is the longest.
Medications: On the Confidential Health Questionnaire, carefully and completely list all prescription and over-thecounter
medications your child takes, complete with dosage, frequency, side effects, and the condition for which it
is prescribed. This includes all medications including naturopathic and herbal remedies and supplements.
Instructors also carry medications in their First Aid Kits. On the Health Questionnaire, please note which First-Aid
kit medications are appropriate to administer to your child, if necessary. Last, a licensed medical personnel must
also list and sign off on prescription medications that your child will take during the trip. AMC instructors are
responsible for carrying and managing ALL medications during the trip for the safety of your child as well as the
other participants. This includes painkillers and commonly used OTC drugs. Send your child’s medications in the
pharmacy’s bottle with the full label attached. Check in with the instructors on the first day of the trip to clarify
any questions about the medications. During a Teen Wilderness Adventure, your child will continue taking any
medications he or she does on a regular basis.
In Case of Emergency: If an emergency arises at home and you must reach your child, call the Education Programs
Coordinator at 603-466-8125. If it is of immediate concern and the coordinator is not available, do not leave a
message, but instead call ext.8117 for the Information Desk at Pinkham Notch Visitor Center (open 6:30am-
10:00pm). An education staff person is on call 24 hours a day to respond to program needs, and the Information
Desk can always reach him or her. Do not plan on your child being able to call home during the trip as the group is
usually far from phones.
Safety: As participant safety is a high priority for all AMC-sponsored events, procedures and policies have been
developed to attempt to limit participant risk. Participants are expected to work with staff to reduce risks and
make the experience successful for all. In case of an emergency, the AMC staff is trained in wilderness first aid,
carry first-aid kits, and follow a comprehensive Emergency Action Plan. The AMC uses radios or other
communication devices -- although these are not reliable in all locations and conditions. Despite such steps,
parents and participants should be aware that there are risks associated with outdoor adventure activities,
including but not limited to cooking and camp chores, adverse weather and environmental conditions, remote
locations of our trips, and transportation in vehicles, on foot, by boat, or on a bike. Please carefully read and sign
the Participant Acknowledgement and Assumption of Risks and Release and Indemnity Agreement and call if you have any
questions. Parents’ and participants’ understanding of these risks and adherence to our policies and procedures
can contribute to making this experience rewarding.
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TEEN WILDERNESS ADVENTURES
WILDERNESS FIRST AID AND RESCUE
AGES 16-18
SUNDAY JULY 21 ST – SUNDAY JULY 28 TH , 2013
To Complete Your Registration: Parents and participants should carefully read and thoroughly complete all the
forms in this packet. Please email all the forms (see list below) back to AMClodging@outdoors.org as soon as
possible, but by June 1, 2013, at the very latest. This will help us to plan the best adventure we can for the group.
We recommend keeping a copy of the forms for your files. We now accept digital signatures- therefore all forms
can be completed on your computer and attached to an email back to us!
Registration Form
Trip Policies Form
Confidential Health Questionnaire- ONE SEPARATE PAGE IS ATTACHED THAT MUST BE COMPLETED
AND SIGNED BY A LICENSED MEDICAL PERSONNEL
Participant Acknowledgment and Assumption of Risks & Release Form (two pages)
Eastern Mountain Sports participant Acknowledgment and Assumption of Risks & Release Form
It is imperative that we receive all completed paperwork prior to the start of the trip!!!! If you
must print and return paper copies please mail or fax them to:
Appalachian Mountain Club Reservations Fax: 603-466-3871
P.O. Box 298, Rte. 16
Gorham, NH 03581
Trip Start: This Teen Wilderness Adventure begins at the Pinkham Notch Visitor Center at 9 a.m. on the first day
of the trip. For driving directions, visit http://www.outdoors.org/lodging/lodges/pnvc/pnvc-directions.cfm.
Upon arrival at Pinkham Notch, check in at the Joe Dodge Lodge. If you wish to arrive the night before, you
should make lodging reservations at Joe Dodge Lodge, 603-466-2727. Parents/guardians are encouraged to
participate during the morning group introductions. Free guided nature walks and hikes are often available at the
same time trips start for parents and families. We encourage anyone making the trip up for drop off to attend.
Check in at the info desk for details.
Trip End: This trip concludes at the Pinkham Notch Visitor Center at approximately 3 p.m. on the last day. Please
be somewhat flexible with your travel plans as this time isn’t always exact.
Itinerary: The participants will meet each other and the AMC instructors on the first morning at the Pinkham
Notch Visitor Center. We will spend the morning getting to know each other, covering logistics and expectations,
and thoroughly checking our personal gear and all group equipment. After lunch we will make any final
equipment adjustments and head up to Hermit Lakes Shelters where we will set up basecamp for the duration of
the trip.
Wilderness First Aid ~ An instructor from Stonehearth Open Learning Opportunities (SOLO) will meet us at
our campsite on day two and spend three days teaching backcountry first aid and CPR. This experiential
section has plenty of hands-on scenarios, including a mock rescue. Particular emphasis is placed on
preventing backcountry emergencies through proper trip planning and equipment selection. Participants
will receive a 16-hour Wilderness First Aid certification (valid for three years) upon successful completion
of this section.
Introduction to Search and Rescue ~ The following three days we will day hike in the Presidentials and
explore search and rescue techniques while learning about the history of this topic in the White Mountains.
This section includes hands-on teaching and practice of search tactics, basic rescue systems, and incident
response practice.
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Cost: Pricing includes instruction, transportation during the course, all meals from lunch on the first day through
lunch on the last day, group equipment (tents, stoves, pot/pans, etc.), all kayaking equipment, and all camping fees
during the program. $1,450 ($1,595 nonmembers)
Cancellation Policy: Reservations canceled more than 30 days in advance will receive a full refund. Reservations
canceled within 14 to 30 days of the program will receive a refund minus 30 percent of the program fee.
Reservations canceled less than 14 days in advance will forfeit the full amount. In the event that the AMC must
cancel a program, registrants will be notified and all course fees and deposits will be refunded. We are unable to
make exceptions to this policy, so we strongly recommend purchasing traveler’s insurance (see next section.)
Traveler’s Insurance: No one expects to cancel or interrupt a planned trip or to incur sudden medical, evacuation,
or other trip delay expenses. The AMC strongly recommends that Teen Wilderness participants purchase travel
insurance to protect themselves against financial loss in the case of a personal emergency or other unforeseen
events. The following link will direct you to a time sensitive travel insurance program called Travel Insurance
Select® for your immediate consideration.
http://www.travelinsure.com/what/selecthigh/htm
You may enroll at any time prior to your departure date. However, to be eligible for additional benefits including
coverage of Pre-Existing Conditions, your enrollment form and premium payment must be received (or, if mailed,
postmarked) within 15 or 21 days of confirmation of your registration, depending on the insurance you select.
Please review the website for complete coverage details and instructions on enrollment. Call us or our
administering agent for Travel Insurance Select®, Travel Services, at 1-800-937-1387, if you have further questions.
For Registration Questions, Contact:
Appalachian Mountain Club Reservations
PO Box 298, Rt. 16
Gorham, NH 03581
Phone: 603-466-2727
Fax: 603-466-3871
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TEEN WILDERNESS ADVENTURES
REGISTRATION FORM
Participant’s Name:_______________________________________
City, State of residence:__________________________
Why did you select the AMC’s Teen Wilderness Adventures program this summer
______________________________________________________________________________________________________________
What type of AMC membership do you have Family Junior Other__________
Did you become a member when registering for this trip Yes I was already a member
How did you first find out about Teen Wilderness Adventures
Teen Wilderness Adventures brochure
Where did you get your brochure ______________
Summer Camp Fair, Location __________________
AMC Destinations (Huts, Lodges, Visitor Centers)
Promotional Mailing
School (name, location):_______________________
A friend gave it to me
Past Experience
Another AMC program
A friend or family member/ word of mouth
AMC Outdoors (member magazine)
AMC’s website (www.outdoors.org)
Facebook/Twitter
Google Search
Other Website (specify site):_______________________
A newspaper/magazine article/ad in:______________
Other (please specify):____________________________
Can you suggest other places to promote Teen Wilderness Adventures______________________________________________
Do you have a friend or family member who might be interested in Teen Wilderness Adventures
Name and address: ____________________________________________________________________________________________
What is your local newspaper (paper, name, city, state) ____________________________________________________________
EXPERIENCE: Please describe any pertinent outdoor experience you have had with (including past AMC Teen Trips) and areas
previously hiked in the White Mountain National Forest to help us in planning.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
EXERCISE: Detail your current activity level below -or- NONE (your honesty with help with planning)
Activity Frequency Per Week Approximate Time/Distance Intensity Level
SWIMMING ABILITY: Cannot swim Can swim 100 feet Can swim 500 feet Strong swimmer
The following release will not affect your standing in the program:
Photo and Quotation Release:
I hereby authorize the Appalachian Mountain Club (AMC) and/or parties designated by the AMC (including
periodicals or other printed matter and their editors) to use my son’s/daughter’s photograph or quotation for sale
or reproduction in any medium the AMC or its designees see fit for purposes of advertising, display, exhibition or
editorial use.
___________________________________________________________
10/11 Parent/Guardian Signature Date
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________________________________________________________________
10/11 Parent/Guardian Signature Date
TEEN WILDERNESS ADVENTURES
TRIP POLICIES FORM
Prior to the start of the program, the participant and parents/guardians must understand and agree to abide by the
following policies and regulations. These policies and regulations are for the safety of the individual, the group,
and the organization.
The Possession And/Or Use Of Tobacco Products: The possession or use of any and all tobacco products is not
acceptable during any of our programs. If individuals are in possession of any tobacco product after the start of the
program, the participant will be sent home immediately.
The Possession And/Or Use Of Alcohol Products or Illegal Drugs: The possession or use of any and all alcohol
products or illegal drugs is not acceptable during any of our programs. If individuals are in possession of any
alcohol products or illegal drugs after the start of the program, the participant will be sent home immediately
and/or turned over to the legal authorities. In addition to being illegal for minors, alcohol and drugs can be very
dangerous in the remote environments where we travel.
The Possession And/Or Use Of Firearms: The possession or use of any and all firearms is not acceptable during
any of our programs. If individuals are in possession of any firearm after the start of the program, the participant
will be sent home immediately.
Sexual Behavior/Coupling: Sexual activity and harassment is prohibited on all AMC programs. Inappropriate
sexual behavior and/or harassment is grounds for a participant to be sent home immediately. Equally important
is the effect on the group of pairing off or "coupling" students. This behavior often divides the group and creates
cliques, possibly resulting in tension within the group and creating and uncomfortable situation for other
participants. This situation may result in a student or students being sent home.
Disruptive Behavior: Students/youth who promote or display disruptive behavior that affects other individuals
or a group situation may be sent home immediately. We expect program participants to respect others in the
group, nurture a sense of community, foster an appreciation for the environment, be enthusiastic in the program’s
activities, contribute to the whole group and on an individual basis, and exhibit tolerance for individual
differences.
Cell Phones and other Electronic Devices*: The possession or use of cell phones, mobile web devices, iPods, mp3
players, portable radios or CD players, portable gaming devices, or other entertainment-related devices is not
permitted. Electronic devices prevent participants from being fully engaged in their outdoor experience, and, these
devices may be damaged or destroyed in outdoor environments. These devices should be left at home, and staff
will confiscate any device found in the field and return it at the end of the trip (we cannot guarantee its condition).
If you and/or your child need to communicate during their AMC adventure, we ask that you work through the
program’s administrative or field staff so communication and plans will be inclusive of all involved. If you have
questions or concerns, we encourage you to call (603) 466-8125.
*This policy does not apply to digital cameras.
If a participant has been caught violating any of the above stated policies/guidelines, the leaders have the
authority to remove the participant from the program/trip without the possibility of returning for any
remaining segments of the trip. Any removal of a participant from a program/trip will result in a forfeiture of
the course fee. Any transportation from the program facility to the home residence of the participant will be at
the expense of the parents/legal guardian.
Parent/Guardian Signature:___________________________________________________ Date:___________
Participant Signature:_________________________________________________________ Date:____________
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Appalachian Mountain Club
Confidential Health Questionnaire
Medical Screening
In order to provide a positive experience for our participants, the AMC collects medical information via
this questionnaire. The AMC offers a range of programs varying in environmental conditions, physical
difficulty, and access to professional medical care. Thus, in an effort to minimize risk for participants, the
AMC utilizes the information gathered from the questionnaire to aid us in matching each participant to the
program that will best suit his/her goals, needs and abilities.
Instructions for Completing the Confidential Health Questionnaire
Forms A, B and C are to be filled out by the parent/guardian. It is essential that the forms are truthfully
and thoroughly filled out. Disclosing medical information upfront will help the AMC provide the
appropriate level of care for your child if necessary. The AMC treats all medical disclosures with
confidentiality. Every participant’s medical information is confidentially stored and is shared with the
participant’s field instructors. AMC staff will review the information gathered on the medical
questionnaire and will contact parents/guardians if questions arise. The AMC wants your son or daughter
to participate in the program and will strive to accommodate most medical conditions.
Please completely list all prescription and over-the-counter medications your child takes, with dosage,
frequency, side effects, and the condition for which it is prescribed. Please attach another page if
necessary. AMC instructors are responsible for carrying and managing ALL medications during the trip
for the safety of your child as well as the other participants. This includes painkillers and commonly used
OTC drugs. Send your child’s medications in the pharmacy’s bottle with the full label attached. During
AMC Programming, your child will continue taking any medications he or she does on a regular basis.
Form D is attached separately and is to be filled out by a licensed medical professional. Acceptable
licensed medical personnel are restricted to Doctors (MD), Registered Nurses, (RN), Licensed Practical
Nurses (LPN), Nurse Practitioner (NP), and Physician Assistants (PA). The AMC requires that each child
has had a physical examination within two years of their trip start date.
If your child has had a physical within 2 years of the trip start date, that physical will fulfill the
AMC’s requirement as long as the examining licensed medical professional completes and signs
Form D of the Health Questionnaire.
Before sending back paperwork, please make sure:
□ A parent/guardian has fully completed Forms A, B and C.
□ A licensed medical professional has fully completed Form D.
AT THE START OF THE TRIP, please check in with the AMC instructors to
answer questions about your child’s medical background or medications.
Please keep all medications out of your child’s pack and deliver them directly to the
AMC instructors.
Thank You
10/11
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Participant Name_____________________________________________ Course Code ____________
Appalachian Mountain Club - Teen Wilderness Adventures
Confidential Health Questionnaire
Parent/Guardian must complete Forms A, B and C for the child participating in AMC activity.
Form A (Please attach another sheet if necessary to record information clearly):
Participant Name: ___________________________________ Trip Start Date: _____________________
AMC Trip Name ______________________________________________________________________
Age at Trip Start: ______ Male/Female: _____ Height: ________ Weight: ________ DOB: ___________
Home Address: ________________________________ Parent/Guardian Email: ____________________
City: _______________________________ State: ______________ Zip Code: ___________________
Parent/Guardian Name(s): ___________________________________Relationship: _________________
Phone Number: (day) ___________________ (eve)_________________ (cell) _____________________
Secondary Emergency Contact: _______________________________Relationship: _________________
Phone Number: (day) ___________________ (eve)_________________ (cell) _____________________
Medical Insurance # ________________ Policy # ______________ Carrier’s Name: ________________
DIETARY RESTRICTIONS: List any food allergies, include the child’s reaction and its severity,
whether it is anaphylaxis and also if the allergy is from ingestion only or if it is airborne.
Please check all that apply:
Vegetarian Vegan No Red Meat Lactose Intolerant Gluten-Free Other
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS DURING AMC
TEEN WILDERNESS ADVENTURE PROGRAM:
I authorize the Teen Wilderness Adventure instructors to assess the need for and appropriately administer
the below checked medications:
Advil (ibuprofen)
Benedryl (diphenhydramine)
Tylenol (acetaminophen)
Pepto Bismol
Parent/Guardian Signature: __________________________________ Date: ____________________
MENTAL, EMOTIONAL, SOCIAL HEALTH QUESTIONNAIRE
1. Has the child ever been treated for emotional or behavioral difficulties or an
eating disorder
2. During the past 12 months, has the child seen a professional to address
mental/emotional health concerns
3. Has the child had a significant life event that continues to affect the child’s life
(History of abuse, death of a loved one, family change, new sibling, survived a disaster, etc.)
If you answered YES to any of questions #1-3 above, please explain in the space below.
_________________________________________________________________________
_________________________________________________________________________
Yes
No
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Participant Name_____________________________________________ Course Code ____________
Form B:
HEALTH HISTORY QUESTIONNAIRE
Has the child: Yes No
1. Experienced an asthma attack at any time in his/her life (Asthma can potentially
be affected by exercising at altitude, in dry air, extreme cold, etc.)
2. Ever been diagnosed with Type I or Type II diabetes (A diabetic can easily
become dehydrated in backcountry environments. Further, long, arduous days/hikes can
lead to hypoglycemia, etc.)
3. Ever visited a medical professional for a serious allergic reaction, or ever been
given a shot of epinephrine for an allergy or anaphylaxis (Some people are allergic
to stinging insects; nut products or other food products which a co-participant might be
carrying or may be included in a meal prepared by AMC staff; iodine, which might be
used to treat drinking water and/or clean wounds, etc.)
4. Ever received medical treatment for angina, a heart attack, or any type of heart
disorder/disease
5. Ever been diagnosed with or is he/she currently being treated for high blood
pressure (The environment and workload associated with AMC courses can
sometimes affect BP and/or the efficiency of some BP medications.)
6. Ever seen a medical professional following a seizure, or is he/she currently being
treated for any type of seizure disorder (Some seizures are triggered by fatigue and
dehydration [which can occur following a long hike], significant change in diet, stress,
etc.)
7. Is there anything else you think we should know about the participant’s medical
background (i.e., anything that could affect his/her safety or ability to participate
fully)
8. Had an up-to-date Tetanus shot Date of last tetanus: _____________
9. Had the required physical examination within two years of the trip start date
If you answered YES to any question #1-7 above, please answer the following as well:
o He/she was diagnosed with ____________________________________ in the last year.
o He/she has visited the emergency room in the last year due to ___________________________.
o He/she has had to use epinephrine following an asthma attack/allergies or anaphylaxis in the last
year ________
o Will he/she be bringing/carrying epinephrine on the outing _______
o What is he/she allergic to ______________________________
o How often does he/she use an inhaler to treat asthma or wheezing _______________________
o Does he/she have poor circulation due to diabetes __________
o Will he/she be carrying insulin or wearing an insulin pump during this trip _________
o Is he/she able to exert him/herself for more than 60 minutes without experiencing angina (chest)
pain _________
o Is he/she currently taking medication for seizures _________
o Has he/she experienced a seizure in the past year _________
o Is his/her blood pressure currently under control (i.e., systolic under 140 and diastolic between 60
and 100) _________
10. Is there anything else we should know about this child’s medical background Attach a separate
sheet if necessary.___________________________________________________________
________________________________________________________________________
10/11
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Participant Name_____________________________________________ Course Code ____________
Form C:
IF YOUR CHILD IS BRINGING NON-PRESCRIPTION (over-the-counter) MEDICATIONS ON A
TEEN WILDERNESS ADVENTURE TRIP, PLEASE COMPLETE AND SIGN THIS SECTION.
(Medications must be in original containers per state law.)
Medication Condition Dosage
(amt/time of day)
Initiated
(month/year)
Side Effects
The above information and directions for assistance of all non-prescription medications is complete and correct. I authorize
the Teen Wilderness Adventures staff to use their discretion in managing the above medications as indicated.
Parent/Guardian Signature: __________________________________ Date: ____________________
IF CHILD IS BRINGING PRESCRIPTION MEDICATIONS ON A TEEN WILDERNESS
ADVENTURE TRIP, PLEASE COMPLETE AND SIGN THIS SECTION. (Medications must be in
original containers per state law. Please attach an additional sheet if necessary.)
Medication Condition Amount Given
per Dose
When it is Given
(check all applicable)
Breakfast
Lunch
Dinner
Bedtime
Other time:_____________
Breakfast
Lunch
Dinner
Bedtime
Other time:_____________
Breakfast
Lunch
Dinner
Bedtime
Other time:_____________
Initiated
(month/year)
Side Effects
The above information and directions for assistance of all prescription medications is complete and correct. I authorize the
Teen Wilderness Adventures staff to hold and distribute the above medications as indicated.
Parent/Guardian Signature: __________________________________ Date: ____________________
PLEASE READ CAREFULLY! (Participants and Parent/Guardians) must read and sign below.
Participant acknowledgement of accuracy and understanding. By signing this form, I am declaring, to the best
of my knowledge, I have completed the questionnaire accurately. I also understand that my knowingly filling out
the form inaccurately, or by withholding pertinent information about the participant’s health, I could potentially be
increasing the risk to him/her or others.
Consent to accept aid. By signing this form, I am giving consent and permission for AMC staff, volunteers,
representatives, or contractors to provide medical care to me or my child, to transport me or my child to a medical
facility or to seek the aid of emergency medical services as deemed appropriate. I further authorize AMC staff,
volunteers, representatives, or contractors to render whatever treatment they consider necessary for my or my
child’s health, and I agree to pay all costs associated with that care and transportation.
Participant’s Name (printed): _________________________ Participant’s signature: ______________________
Participant Name_____________________________________________ Course Code ____________
Parent/Guardian Signature: ________________________________ Date: _________________ 10/11
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AMC PARTICIPANT
ACKNOWLEDGMENT AND ASSUMPTION OF RISKS & RELEASE AND INDEMNITY AGREEMENT
INTRODUCTION
PLEASE READ THIS ENTIRE TWO-PAGE DOCUMENT (hereafter 'Document') CAREFULLY BEFORE SIGNING. All participants must sign this
Document. For participants under 18 yrs. of age (hereafter sometimes ‘minor’ or ‘child’), one or both parent/s or guardian/s (hereafter
collectively ‘parent/s’) must also sign. In consideration of the services of the Appalachian Mountain Club, Inc., a charitable, not-for-profit
corporation, organized and existing under the laws of Massachusetts, and its chapters, including all officers, directors, employees, representatives,
agents, independent contractors, volunteers (including leaders and co-leaders), members and all other persons or entities associated with it
(collectively referred to in this Document as 'AMC'), I (participant and parent/s of a minor participant), acknowledge and agree as follows:
Appalachian Mountain Club contracts with individuals or organizations that are independent contractors (not employees or agents of Appalachian
Mountain Club) to conduct some of the activities participants may engage in. Although the Appalachian Mountain Club has made efforts to locate
responsible contractors, it does not supervise or control these contractors and is not responsible for their conduct. Participant (and parent/s)
acknowledge that they may independently investigate and assess these organizations and activities, if they choose to do so. Further, Appalachian
Mountain Club uses volunteers to assist with, and sometimes lead activities, workshops or programs. These individuals are not paid
professional guides or leaders. In all activities, all participants share in the responsibility for their own safety and the safety of the group.
ACKNOWLEDGMENT & ASSUMPTION OF RISKS
AMC instructional, educational and/or adventure activities (which may be scheduled or unscheduled, supervised or unsupervised and/or occur during
free time) include, but are not limited to hiking, backpacking, camping, biking, skiing, snowboarding, snowshoeing, high and low ropes courses, trail
work, maintenance of facilities, mountaineering, rock and ice climbing, canoeing, kayaking, sailing, swimming, environmental education, wilderness
emergency medical training, first aid and rescue, participation in volunteer service projects, use of AMC huts or other facilities and transportation or
travel to and from activities (referred to in this Document as 'activities' or 'these activities'). These activities include inherent and other risks,
hazards and dangers (referred to in this Document as ‘risks’) that can cause or lead to injury, damage, death or other loss to participant or
others. The following includes some, but not all of those risks:
Risks present in an outdoor, mountainous or wilderness environment on land or water, both on and off trail. Travel can be subject to storms,
strong winds, avalanches, currents, waves, whitewater, lightning, rapidly moving rivers or other water bodies, difficult stream crossings, snow or ice,
extremely hot, humid or cold weather or water, steep terrain, falling rock, stinging or disease carrying animals or insects, wild animals and other
natural or human-made hazards and dangers. Hazards may not be marked and weather is unpredictable year-round.
Risks in decision making, including, without limitation, the risk that an AMC staff member, volunteer, representative, co-participant or contractor may
misjudge a participant’s capabilities, health or fitness level, or misjudge some aspect of instruction, medical treatment, weather, terrain, water level, or
route location.
Personal health and participation risks. The risk that a participant’s mental, physical or emotional condition (disclosed or undisclosed, known or
unknown) combined with participation in these activities could result in injury, damage, death or other loss.
The risk that equipment used in an activity may be misused, or may break, fail or malfunction.
AMC activities may take place in remote places, several hours or days from any medical facility, causing potential delays or difficulties with
communication, transportation, evacuation and medical care.
Risks connected with meals and/or cooking and camping chores. Meals may include exposure to food allergens. Risks also include gas
explosion, scalding or other burns associated with cooking over a gas stove or open fire, and water contamination from natural water sources. All
water may be contaminated and should be disinfected, filtered or boiled before use.
Risks associated with AMC facilities and premises, including boulders, ruts, slippery walkways, ponds or other water sources, uneven ground or
other conditions.
Risks associated with transportation. Travel can be on foot or by vehicle, bicycle, boat or other means and can be over rough and unpredictable
terrain or via oceans or rivers, with wind, rain, or other adverse weather conditions.
Volunteer community service. Risks associated with activities such as (but not limited to) building, digging and trail maintenance, painting,
construction and clean-up projects. Projects can include the use of tools and equipment (i.e. drills, saws, power tools) that can cause injury resulting
from use, misuse or malfunction.
Risks regarding conduct, including the potential that the participant, or other participants or third parties (e.g. general public, rescue squad, medical
facility) may act carelessly or recklessly.
Participants may have limited, unsupervised time during, before or after the start of an AMC program. This may include periods of free time, or
periods of time alone while engaged in backcountry travel. During both supervised and unsupervised activities, all participants share in the
responsibility for their own safety and the safety of the group.
Other risks that are generally associated with instructional, educational and/or adventure activities.
These and other risks may result in participants falling, being struck, colliding with objects or people, experiencing vehicle or boat collision
or capsize, drowning, reacting to weather conditions or increased exertion, suffering gastro-intestinal complications or allergic reactions,
becoming lost or disoriented, or experiencing other problems. These and other circumstances may cause hyperthermia, hypothermia,
frostbite, dehydration, burns, heart or lung complications, broken bones, concussions, paralysis, mental or emotional trauma, or other
injury, damage, death or loss.
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I (participant and parent/s of a minor participant) agree:
• To accurately complete all required forms (which may include, but is not limited to the AMC application, registration and medical forms), abide by
the terms of those documents, and obey all AMC rules, regulations and policies;
• If participant has any mental, physical or emotional conditions or limitations that might affect his/her ability to participate I agree to disclose those
to AMC, and represent that participant is fully capable of participating without causing harm to him/herself or others;
• AMC representatives are, and have been available, should I have further questions about these activities and the associated risks;
• AMC staff, leaders or other personnel cannot assure participant's safety or eliminate any of these risks.
Participant is voluntarily participating with knowledge of the risks. Therefore, participant (and parent/s of minors) assume and accept full
responsibility for the inherent and other risks (both known and unknown) of these activities, and for any injury, damage, death or other loss
suffered by participant (and parent/s of minors), resulting from those risks and/or resulting from participant’s negligence or other
misconduct.
RELEASE AND INDEMNITY AGREEMENT
Please read carefully. This Release and Indemnity agreement contains a surrender of certain legal rights. I (adult participant, or parent/s
for themselves and for and on behalf of their participating minor child) agree as follows:
(1) to release and agree not to sue AMC, with respect to any and all claims, liabilities, suits or expenses (including attorneys’ fees and costs)
(hereafter collectively ‘claim’ or ‘claim/s’) for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or
participation in these activities, or use of AMC equipment, facilities or premises. I understand I agree here to waive all claim/s I or my child
may have against AMC, and agree that neither I, my child, or anyone acting on my or my child’s behalf, will make a claim against
AMC, as a result of any injury, damage, death or other loss suffered by me or my child;
(2) to defend and indemnify (‘indemnify’ meaning protect by reimbursement or payment) AMC with respect to any and all claim/s brought by or on
behalf of me, my child or a family member for any injury, damage, death or other loss in any way connected with my/my child's enrollment or
participation in these activities or use of AMC equipment, facilities or premises.
This Release and Indemnity Agreement includes claim/s resulting from AMC’s negligence (but not its gross negligence or intentional or
reckless misconduct), and includes claim/s for personal injury or wrongful death (including claim/s related to emergency or medical
response, assessment or treatment), property damage, breach of contract or any other claim.
CONCLUSION
I (participant and parent/s of a minor participant) agree that the substantive laws of Massachusetts govern this Document, any dispute I have with
AMC and all other aspects of my relationship with AMC, and that any mediation, suit, or other proceeding must be filed or entered into only in
Massachusetts.
AMC reserves the right to remove any participant from the program who staff or leaders believe, in their discretion, presents a safety concern or
medical risk, is disruptive, or acts in any manner detrimental to the program. If participant is dismissed or departs for any reason, participant (and
his/her family) are responsible for all costs of early departure whether for medical reasons, dismissal, personal emergencies or otherwise. These
costs include, but are not limited to medical evacuation and costs, plane, train or taxi fare, accommodations, and costs and compensation for staff
accompanying participant.
This Document is intended to be interpreted and enforced to the fullest extent allowed by law. Any portion of this Document deemed
unlawful or unenforceable shall not affect the remaining provisions, and those remaining provisions shall continue in full force and effect.
Participant and parent/s of a minor participant agree: I have carefully read, understand and voluntarily sign this two-page Document and
acknowledge that it shall be effective and binding upon me, my minor children and other family members, and my heirs, executors,
representatives and estate. One or both parent/s must sign below for any participating minor (those under 18 years of age).
____________________________________________ _______________ __________________________________________
Participant Signature Date Print name here
____________________________________________ _______________ __________________________________________
Parent or Guardian Signature Date Print name here
____________________________________________ _______________ __________________________________________
Parent or Guardian Signature Date Print name here
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RELEASE AND ASSUMPTION OF RISK AGREEMENT
For CLIMBING SCHOOL ACTIVITIES
Notice: Read this document carefully. This document affects your legal rights, and contains waivers and releases
of your rights.
Each person participating in any activity offered by Eastern Mountain Sports must sign this document. A parent or
legal guardian of each participant who is a minor under 18 years old must also sign this document in both his/her
individual capacity and his/her capacity the parent or guardian of the minor in order to bind the minor as if he/she
was at least 18 years old.
Each reference to “I” or “me” that appears below refers to each adult signing this Agreement and each minor
Participant for whom I am signing this Agreement as her/his parent or legal guardian.
I wish to participate in mountain, artificial rock wall, rock and/or ice climbing instruction and activities and other
related hiking and trekking activities offered by the Eastern Mountain Sports Climbing School (the “Activity”).
I acknowledge that my participation in the Activity involves known and unanticipated risks which could result in
physical or emotional injury, musculoskeletal injuries, head injuries, paralysis, death or damage to myself, to property, or to
third parties. I understand that such risks cannot be eliminated without jeopardizing the essential qualities of the Activity.
The risks include, among other things, my own or other person’s negligence, and:
Participating beyond my personal limits;
Poor or impaired balance, physical coordination
or ability to follow instruction;
The fact that illness, injury or accident may occur
far from medical care facilities;
Equipment defects or malfunctions;
Falling on others or others falling on me;
Falling off snowshoes, skiis, or other equipment;
Falling onto the ground, trees or into bodies of
water;
Trees, branches, rocks falling on me, including
avalanches and rockslides;
Slipping, falling or losing control of equipment on
rough, steep, slippery or frozen mountains, rock
surfaces or other terrain;
Exposure to natural elements, the forces of
nature and environmental hazards;
Exposure to high altitude which may affect
coordination, reaction time, and judgment,
perception and thinking;
Weather conditions, including very cold weather,
heat, sun exposure, and possible resulting
hypothermia, hyperthermia, exhaustion, sunburn,
heat stroke, dehydration, frostbite, and frostnip;
Drowning and hazards associated with water
levels, movements and conditions and exposure
to cold water in rivers, lakes and other bodies of
water;
Encountering or attack by snakes, other reptiles,
insects and other animals;
Possible firing of firearms by hunters or others;
Vehicular and other accidents while traveling to
and from Activity sites;
I expressly agree and promise to accept and assume all of the risks existing in the Activity. My participation in the
Activity is purely voluntary, and I elect to participate in spite of the risks.
I certify that I am in good health and capable of participating in the Activity. I grant permission to Eastern Mountain
Sports to seek and obtain medical care for me and any minor for whom I have signed this Agreement for injury or illness
occurring as a result of or otherwise during participation in the Activity.
I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Eastern Mountain Sports
and its shareholders, directors, officers, employees and agents (all of which are collectively called the “Released Parties”),
from and against any and all claims, demands or causes of action which are in any way connected with my participation in
the Activity or my use of equipment or facilities provided by Eastern Mountain Sports, including any such claims which allege
negligent acts or omissions by any of the Released Parties. I confirm that the foregoing release of claims and indemnification
are intended to cover all claims whether or not known, suspected or anticipated at this time, and I waive the benefit of any
law that would purport to limit the scope or effect of the release and indemnification, whether by excluding unknown,
unsuspected or unanticipated claims or in any other manner.
I also agree that I will not bring any lawsuit or other legal proceeding against any Released Party based on my
participation in the Activity. Should any of the Released Parties be required to incur attorneys’ fees and costs to enforce this
agreement, I agree to indemnify and reimburse them for such fees and costs.
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I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, and in
all events agree to bear the costs of such injury or damage myself. I further certify that I have no medical or physical
conditions that could interfere with my safety in the Activity, or if I do have such a condition, I assume – and bear the costs of
– all risks that may be created, directly or indirectly, by the condition.
By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in the
Activity, I have waived my right to maintain a lawsuit against any Released Party on the basis of any claim from which I have
released it herein.
I acknowledge that Eastern Mountain Sports may take photographs and video and sound recordings of me in
conjunction with participation in the Activity. I grant Eastern Mountain Sports the unconditional and irrevocable right to use,
re-use, publish and exhibit the photographs and/or recordings and/or my name, either alone or accompanied by other
information or material, in any manner and in any medium now or hereinafter known throughout the world, in whole or in part,
in edited, modified or altered format, at any time hereafter for advertising, promotional or any other purpose whatsoever. All
photographs will become and remain the sole and exclusive property of Eastern Mountain Sports, and I will not retain,
acquire nor assert now or in the future any right, title or interest in them. Eastern Mountain Sports shall have no obligation or
responsibility whatsoever to me in connection with the photographs or the granting of these rights. I hereby waive and
release and forever discharge the Released Parties from any claims that I may now or in the future have in connection with
the use of my name and/or the photographs and recordings.
I have had sufficient opportunity to read this entire document. I have read and understood it, have signed it knowingly and
voluntarily, and agree to be bound by its terms. I acknowledge receipt of a copy of this agreement.
If I am signing this agreement as a parent or legal guardian of a minor under age 18, I confirm that I am granting
permission for that minor to participate in the Activity. I specifically confirm that I am providing the releases,
discharges, indemnifications and other assurances, certifications and agreements contained herein on behalf of
myself and any minor under age 18 for whom I am signing this Release and Assumption of Risk Agreement and that
each reference to “I” or “me” shall in this Agreement shall refer to me and to each minor for whom I am signing as
her/his parent or legal guardian.
Parent/Adult Participant Name (Print LEGIBLY):
_________________________________________________
Today’s Date: _____/_____/______
Adult Participant Age: ________
Home Address: __________________________________ ________________ _____ __________
(current street address) (city) (state) (zipcode)
Telephone Number: _____________________________
Email Address: ___________________________________
Parent/Adult Participant Signature:________________________________________________________________________
Minor Participant (Write “NONE” in the space below if you are not signing for any Participants under age 18)
Minor Participant Name: _____________________________________
If any Minor Participant is listed above, complete the following:
I have read the Release and Assumption Of Risk Agreement, have discussed it with my parent or legal guardian, and have
had the opportunity to ask any questions that I have about the Activity and the hazards and risks associated with it.
Minor Participant Signature (below):
_____________________________________
Today’s Date: _____/_____/______
Minor Participant Age: ________
Home Address: __________________________________ ________________ _____ __________
(current street address) (city) (state) (zipcode)
Telephone Number: _____________________________
PLEASE GIVE THE COMPLETED AND SIGNED RELEASE AND ASSUMPTION OF RISK AGREEMENT TO
EASTERN MOUNTAIN SPORTS STAFF.
PLEASE RETAIN A COPY OF THIS RELEASE AND ASSUMPTION OF RISK AGREEMENT FOR YOUR RECORDS.
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