Offered by the High Mountain Institute and Full Circle of Lake County

Lake County Backpacking Trip Free trip for Lake County students completing 7

th or 8

th grade

July 23 – July 28, 2018

Join your classmates from Lake County Middle School for a fun week long camping trip this summer in the spectacular Sawatch Mountains above Leadville. Visit beautiful high alpine lakes, learn how to cook pizza on a camp stove, sleep under the stars, make great new friends, and challenge yourself! The trip is FREE

for all participants and will be run by the High Mountain Institute in partnership with Full Circle and the Lake County School District. No experience is necessary.

Sample Itinerary: Monday, July 23

rd – Tuesday, July 24

th: The first two days will be spent

on our campus getting to know each other and preparing for the upcoming camping trip. We learn how to set up a tent, cook a meal on a camping stove, and read a map. We'll also go on a couple of short day hikes to warm up our hiking legs and go for a refreshing dip in Turquoise Lake.

Transportation is provided to the High Mountain Institute's campus on the first day (just outside Leadville by the Fish Hatchery) and back home at the end of the trip (on Saturday). We will spend the first two nights camping out on HMI’s campus. On the final day before our camping trip, we pack all of the food and gear that we'll need for our four-day trip. All equipment will be provided.

Wednesday, July 25th

– Saturday, July 28th (three overnights): Then it is off into the backcountry for four days of

backpacking! We’ll hike through the spectacular Sawatch Mountains above Leadville. At night, we'll camp near crystal-clear alpine lakes and under star-lit skies. Over the course of the trip, we’ll learn the basic skills to camp and travel comfortably in the wilderness. At the end of the trip, our minds will be full with memories of the beautiful views, four days of laughter, and all that we have accomplished.

Frequently asked questions: Is previous outdoor experience required? No, you don't need any previous outdoor experience to participate in the Lake County Summer Backpacking Trip. We'll teach you the skills you need to camp and travel comfortably in the wilderness. All you need is a willingness to try new things.

What equipment do I need? We'll provide you with a packing list before the trip. All equipment that you need for the trip can be borrowed from the High Mountain Institute for free.

Offered by the High Mountain Institute and Full Circle of Lake County

What kind of food will we eat while in the wilderness? One of the things we like to do is to eat good food (and lots of it!). You'll have lots of ingredients with you—pasta, rice, cheese, flour, bagels, tortillas, sugar, spices—for you to use in making delicious meals. Typical breakfasts include pancakes, cinnamon rolls, and oatmeal; you'll often eat rice and bean burritos, pasta with cheese and veggies, or pizza for dinner.

Where will we sleep while on the camping trip? While in the wilderness you'll sleep in a tent with 2-4 other students. Boys and girls will sleep in separate tents.

How many students can participate and how are they selected? Up to 24 students from the Lake County Middle School who are currently finishing either 7

th or 8

th grade can

participate this summer. If we have more than 24 applicants, we will select participants using a lottery system. Groups will consist of 8-12 students with two-three instructors.

Who will my leaders be? The leaders for the Lake County Summer Backpacking Trip will include Barrett Donovan and Ari Gino (7

th grade teacher at LCIS) from the High

Mountain Institute, and Abby Mortimer and Jenny Delcher from Full Circle. All of the leaders are trained in wilderness medicine and have many years of experience leading trips in the outdoors.

Do I need to be a Full Circle student to participate? No, the trip is open to any Lake County Middle School students who are currently finishing either 7

th or 8

th grade.

If I did the trip last year, can I participate again this year? Priority is given to students who have not yet completed the Lake County Summer Backpacking Trip. However, if there are any spaces available after May 4th, we would love to have you participate again.

Do I need medical insurance to participate in the Lake County Summer Backpacking Trip? No. All students are welcome to participate in the Lake County Summer Backpacking Trip regardless of whether they have medical insurance. We will buy short term insurance for any uninsured students (no physical is required) so that they have coverage for the duration of the trip.

What is the High Mountain Institute? The High Mountain Institute is a small, educational non-profit located just outside Leadville near the Fish Hatchery. Working with teenagers is our specialty. Our main program is the HMI Semester, a semester-long academic and wilderness program for successful high school juniors. We also offer a variety of summer programs, including the Summer Term and the High Peaks Adventure.

The following students have completed the Lake County Backpacking Trip: 2014: Ariel and Caroline Benney, Domonique Cooke, Tiana Drake, Angel Gonzales, Omar Hernandez, Travis Kerrigan, German

Leanos, Ruben Luna, Abi Reigel, Brayhan and Stephanie Reveles, and Matthew Wadsworth.

2015: Julian Cannell, Tiana Drake, Abigail and Hannah Holm, Matt Koch, Derrick Montoya, Zamira and Andrea Olave, Johnny Ramirez and Stephanie Reveles.

2016: Abram Dallas, Allie Collins, Mark Pacheco, Quentin Shehan, Brando Azeltine, Dylan Windorski, Fenna Tufte, Finbar Cremin, Taylor Duel, Dakota Eanes, Steve Valdez, Brennan Counsell, Yasmine Pereida, Kyle Rongstad, Elijah Smith, Eddie Dominguez, Bianca Harris, Evelyn Villalobos, and Joey Medina.

2017: Zander Bertonneau, Matt Cairns, Jon Jon Espinoza, Elijah Ferguson, Paige Glenny, Cody Hall, Jack Helmke, Jude Hill, Kayleen Macias, Indigo Miller-Barnes, Emma Mimms, Kaytlin Sprague, Fenna Tufte, Evelyn Villalobos, Morgan Wadsworth, Emily Weaver

How do I sign-up? Please complete the attached application form and return it to the front desk at the Lake County High School, to a GOL! representative, to Abby Mortimer from Full Circle (719-486-2400; girls@fullcircleleadville.org), or to Libbey Holewski from the High Mountain Institute (719-486-8200 ext 107; lholewski@hminet.org; 531 CR 5A, Leadville, CO 80461). Additional copies of the application form are available online at: https://www.hminet.org/programs/lake-county-backpacking-trip/ The application deadline is May 4th.

LAKE COUNTY BACKPACKING TRIP OFFERED BY THE HIGH MOUNTAIN INSTITUTE & FULL CIRCLE

Application for the Lake County Backpacking Trip

PARTICIPANT’S CONTACT INFORMATION

Full Name

Name you go by Male / Female

Mailing Address

Physical Address

City, State, Zip

E-mail Address Cell Phone

Date of Birth Current School Grade

PARENTS’/GUARDIANS’ CONTACT INFORMATION

Legal Guardian/Parent 1 Title & Name

Legal Guardian/Parent 2 Title & Name

Step Parent Title & Name

Step Parent Title & Name

Home Address Home Address

Home City, State, Zip Home City, State, Zip

Home Phone Home Phone

Cell Phone Cell Pone

E-mail Address E-mail Address

Business/Occupation (opt) Business/Occupation (opt)

Work Phone (opt) Work Phone (opt)

Send all information to: [ ]Parent 1 [ ]Parent 2 [ ] Student (mark all that are applicable)

Participant Name

Date

Participant Signature

Parent or Guardian Name

Date

Parent or Guardian Signature

2nd

Parent or Guardian Name

Date

2nd

Parent or Guardian Signature

Please note: Applications are due Thursday, May 4th. Please complete the attached application form and return it to the front desk at the Lake County High School, to a GOL! representative, to Abby Mortimer from Full Circle (719-486-2400; girls@fullcircleleadville.org), or to Libbey Holewski from the High Mountain Institute (719-486-8200 ext 107; lholewski@hminet.org; 531 CR 5A, Leadville, CO 80461). We will notify you by May 11th if you have been selected for the program.

ENROLLMENT AGREEMENT LAKE COUNTY BACKPACKING TRIP

Page 1 of 2

The student named below intends to enroll in the Lake County Backpacking Trip (hereafter sometimes, the “Program”) at the High

Mountain Institute. In consideration of the services of the High Mountain Institute, Inc. and the Lake County Summer Backpacking Trip (collectively referred to as “the High Mountain Institute” or “HMI”) the student and his or her parent/s or legal guardian/s (collectively referred to here as “parent/s”) acknowledge and agree as follows:

Enrollment and Additional Forms

A student is considered preliminarily enrolled in the Lake County Summer Backpacking Trip once we receive this signed Enrollment Agreement. We also require the submission of additional forms and paperwork. Therefore, final acceptance, enrollment and participation in the Program is contingent upon our receipt and review of all signed student paperwork and forms, including

the student’s complete Medical Form and the Acknowledgment and Assumption of Risks & Release and Indemnity Agreement.

Separation

HMI reserves the right, in its sole discretion, to separate (including any suspension or expulsion) students from the Program, for any of the reasons identified in this Enrollment Agreement or otherwise. This includes, but is not limited to, separation for medical issues, physical injuries, emotional issues, discipline or behavioral issues, negative or non-participation, failure to follow HMI rules, failure to uphold HMI community standards, and/or other conduct or circumstances that HMI believes, in its sole discretion, is detrimental to the Program. Program Alterations and Force Majeure

HMI endeavors to follow Program itineraries as may be described in HMI marketing materials or other Program information. However, HMI reserves the right, in its sole discretion, to alter itineraries or planned activities, as needed, to address changing conditions, for the health and well-being of students/staff or for other reasons. HMI will not be legally liable or responsible for any delay or failure of its performance regarding the Program and/or under this Agreement including any changes in the Program itinerary, cancellation or other alteration, resulting from an Act of God or other condition beyond its control (force majeure), including but not limited to fire or other natural disaster; war, violence or terrorism or other major event. Typically, these are events that may compromise the health or well-being of students/staff or otherwise prevent performance. In such a case, HMI will suspend or alter its performance if and until, in its sole discretion, it is able to appropriately resume performance. Medical Insurance

All students are required to have medical insurance in place for the duration of the Program. If the student does not have medical insurance, please contact us immediately so that we can assist you in discussing options for coverage.

Student Conduct

HMI has high expectations for student conduct and behavior. Upon arrival at the Program, students will participate in an orientation and will discuss the nature of the Program community, rules and standards of conduct and student responsibilities within the Program community. HMI discusses community rules, norms and expectations with students intermittently throughout the Program in community meetings, on expeditions and otherwise, and includes information on these subjects in written materials and in ongoing communications with parent/s. In signing this Enrollment Agreement, the student agrees to abide by the standards of conduct that support the goals of the

Lake County Backpacking Trip. The success of the community depends upon the full and positive participation of all members.

Parent/s and students must understand that these eight rules are expellable offenses. They are:

Plagiarizing, cheating, or lying

Stealing

Willful destruction of property

Use or possession of alcohol or drugs

Harassment, bullying, hateful or negative speech of any kind

Being in “Never-Known” locations

Sexual activity, specifically intercourse

Use or possession of tobacco products

Photo & Statement Authorization The student and parent/s authorize HMI, and/or parties it designates, to photograph, film, record and/or otherwise capture the name, image, voice, verbal or written statement/s (including quotations from conversations and correspondence), photograph and/or visual likeness (collectively “images”) of the student, parent/s or other family member/s and use those images in any media throughout the world, in perpetuity, including for broadcast, sale, reproduction or display on the internet (including the HMI website or other internet sites), or in motion pictures, audio or video recordings, HMI catalogues, marketing presentations and/or other form for any informational, promotional or educational purpose without compensation to student or parent/s. These images are the sole property of HMI and the student and parent/s waive any inspection or approval rights.

ENROLLMENT AGREEMENT LAKE COUNTY BACKPACKING TRIP

Page 2 of 2

Lost, Stolen or Damaged Property

HMI is not responsible for a student’s lost, stolen or damaged personal equipment or property. In addition, students and their parents will be held responsible for the student’s role in damage to or loss of HMI property or equipment. This may include sharing in the group’s collective responsibility for willful equipment/property destruction or loss.

For all Students and Parent/s I have read, understand, and agree to the terms outlined in this Agreement. I agree to obey all HMI rules, regulations, and policies,

review and accurately complete all forms and information. Parent/s give the student permission to participate in all Program activities, whether occurring on or off HMI property. Colorado law (without regard to its conflict of laws rules) governs all aspects of the student’s or parent/s’ relationship with HMI, contractual or otherwise, and any mediation, suit, or other dispute with HMI must be filed or entered into only in Lake County, Colorado. I agree to attempt to settle any dispute (not settled by discussion) before a mutually acceptable Colorado mediator. The student must sign below. One of the student’s parent/s, or both parent/s, if available, must also sign below.

Print Student Name Print 1st Parent/Guardian Name Print 2

nd Parent/Guardian Name

Student Signature 1st Parent/Guardian Signature 2

nd Parent/Guardian Signature

Date Date Date

Acknowledgement and Assumption of Risks & Release and Indemnity Agreement

Page 1 of 4

Please read and review this entire Document carefully!

Dear Student/Participant and Parents,

The Acknowledgment and Assumption of Risks & Release and Indemnity Agreement represents a part of the High Mountain Institute’s (HMI) risk management practices. Please read the entire Document carefully!

The “Activities and Risks” and “Acknowledgement and Assumption of Risks” sections explain some of the activities participants will engage in, some of the inherent and other risks participants may face and possible outcomes, and contains your acknowledgment, acceptance, and assumption of risks. HMI cannot predict every possible scenario; we have simply listed numerous examples. We seek to inform you of the kinds of activities, risks, and possible outcomes participants will be facing. If you have question or concerns, we expect you to contact us.

Why does HMI not promise a “safe program”? Because a “safe program” would mean not exposing participants to any risk. Participants are exposed to risk by skiing in avalanche terrain, climbing mountains, and splitting firewood. HMI activities, such as these, have inherent and other risks and are part of our programs.

Inherent risks are those that are intrinsic to the activity; without inherent risks an activity loses its essential nature or benefit. For example, the risk of injury from lightning increases as one climbs higher, and is an inherent risk of peak ascents. While HMI staff or others can make judgments about some of the risks and consequences, there is no way to guarantee safety. Judgment is not infallible and misjudgment by HMI staff, participants or others is one of the most significant inherent risks.

The “Release and Indemnity Agreement” section releases and indemnifies HMI from certain claims made against HMI. HMI does not seek this protection with regard to gross negligence or willful or wanton misconduct. HMI does seek protection from negligence and all inherent and other risks, including misjudgment.

HMI seeks this protection because of the litigious climate in our society today. The prospect of lawsuits, before judges and juries who may or may not understand HMI programs is a real and significant issue for HMI. HMI is reserving the right to invoke these documents as we see fit. This is the result of circumstances that neither you nor HMI created. If you are uncertain about the meaning or significance of this Acknowledgment and Assumption of Risks & Release and Indemnity Agreement, you should consult an attorney before signing.

Our hope is that you have confidence in HMI. If you do not have this confidence, you should not come on a HMI program. Please contact me directly with questions or concerns.

Sincerely,

Justin T. Talbot Director of Wilderness Programs and Risk Management

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Acknowledgement and Assumption of Risks & Release and Indemnity Agreement

Page 2 of 4

Please read and review this entire Document carefully!

Introduction: Please review this Acknowledgment and Assumption of Risks & Release and Indemnity Agreement (hereafter “Document”) carefully before signing. The student/participant (hereafter "participant”) must sign this Document. If participant is under 18 yrs. of age (hereafter sometimes “minor” or “child”), one of the participant’s parents or legal guardians, or both (hereafter collectively “parent” or “parent/s”), if available, must also sign. In consideration of the services of the High Mountain Institute, Inc., and its officers, trustees, advisors, board members, employees (including faculty and other staff), agents, representatives, physician advisors, apprentices, volunteers, member schools and all other affiliated persons or entities (individually and collectively referred to in this Document as “HMI”) in allowing me/my child to participate, I (participant and parent/s of a minor participant) acknowledge and agree as follows:

Activities and Risks: Participating (whether attending, observing or actively participating) in HMI educational, instructional, recreational and/or adventure activities includes risks. Activities can take place in Colorado, including on and around the HMI premises, or in other locations in the U.S. or in foreign countries. I acknowledge that the inherent and other risks, hazards and dangers (collectively referred to in this Document as “risks”) associated with these activities can cause injury, damage, death or other loss to participant or others. Some, but not all of the activities, which may be mandatory or optional, scheduled or unscheduled, supervised or unsupervised, or occur as independent opportunities (e.g. vacations, special trips, trips with sub-contractors) (collectively referred to in this Document as “activities”) include:

Travel and living in rustic, rural and/or remote mountainous and wilderness settings Chores: building fires (inside or outside), splitting firewood, cooking, shoveling snow Use of liquid fuel (gasoline) stoves and lanterns Transportation in planes, 15 passenger vans & other vehicles Wilderness first aid and rescue, real and simulated Work or service projects using hand & power tools Independent travel or solo time (without direct supervision) Mountaineering, backpacking, camping, rock climbing, belaying, rappelling, skiing,

canoeing, whitewater rafting, biking, swimming, horseback riding, sports, games, athletic activities

Participant leadership opportunities (by peers or self) Participant socializing and other activities during class time, free, unscheduled and/or independent time, or any other time Leadership & supervision by HMI staff, apprentices (interns) or sub- contractors Sustained walking, hiking, running, carrying, and lifting Use of any equipment, facilities or premises

Some, but not all of the risks that participants may or will be exposed to include:

Misjudgments by self or others, including HMI staff Inappropriate conduct or negligence by self, others, or HMI staff Participant's mental, physical, or emotional condition/s (known or unknown, disclosed or undisclosed) combined with participation Stressful and emotionally intense wilderness, residential & academic experiences Unpredictable weather, extreme cold & heat, storms & lightning, rain, snow, hail Unmarked or obscured hazards on land or in water Moving water in streams & rivers, whitewater, difficult stream crossings, flash floods High altitudes up to or above 10,000 feet Steep slopes, difficult terrain, downed trees Falling: rocks, ice, snow, branches, and trees Snow avalanches, snow, mud or rock slides, & collapsing snow shelters Unpredictable animal behavior (wild or domestic) Failure or misuse of equipment (whether participant’s own, or borrowed, rented or purchased from HMI or other source)

Gas explosion or fire, contaminated water or food or food allergens Wireless communication devices that are unreliable in all settings Occasional one-on-one supervision by staff or apprentices; no supervision during sleeping hours Remote locations, hours or days from help causing delays or complications in communication, evacuation or medical care Dangerous road or travel conditions and transportation problems Falling down or slipping, being submerged in water, snow or debris Animals, insects or microorganisms: stings, bites, poisoning, & blows HMI premises risks, including slippery walkways, uneven ground, use of indoor climbing wall or other risks Other risks associated with educational, instructional,

recreational &/or adventure activities

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Acknowledgement and Assumption of Risks & Release and Indemnity Agreement

Page 3 of 4

Please read and review this entire Document carefully!

These and other activities and risks can result in (for example):

Falls, being struck, or colliding with objects or people Experiencing vehicle or boat capsize or collision Drowning or suffocation Becoming lost or disoriented Injuries due to heat, cold, altitude, heavy exertion Unusual/unknown or known Illness, infection or disease: long or short term, including animal/insect borne or contagious diseases

Gastrointestinal problems or allergic reactions Dehydration Broken bones, concussions, wounds, cuts, burns Property damage or loss Heart or lung complications Mental/emotional trauma, temporary or permanent Other injury, damage, paralysis or other permanent disability, death or loss

I (participant and parent/s of a minor participant) further acknowledge and agree: To read all HMI information received; review, complete and sign the required forms and paperwork and abide by the terms

of those documents (e.g. Enrollment Agreement and Medical Forms); HMI staff are and have been available, should I have questions about the nature and physical demands of these activities

and the associated risks. Parent/s give permission for their child to participate in all HMI activities and agree to discuss the nature of these activities and risks with their child;

HMI contracts with individuals or organizations who are independent contractors (not its employees or agents) to conduct some of the activities participants may engage in. HMI does not supervise or control these contractors and is not legally liable or responsible for their conduct;

HMI requires helmets or other safety gear for some activities. Use of safety gear may prevent or lessen injuries in some instances but is not a guarantee of safety, and injuries can occur even with the use of this gear;

If participant is borrowing, renting or purchasing new or used equipment from HMI, the equipment comes “AS-IS,” and HMI disclaims all warranties, express or implied (including any conditions of merchantability or fitness for a particular purpose) with regard to the equipment. Participant agrees to inspect all equipment before use and

notify HMI of any apparent problems or defects with the equipment.

Acknowledgment and Assumption of Risks: Information provided above is not complete, other unknown or unanticipated activities, risks or outcomes may exist and HMI cannot assure participant’s safety or eliminate any of these risks. All participants share in the responsibility for their own well-being. Participant is voluntarily participating with knowledge of the risks, and can do so without causing harm to himself/herself or others. Therefore, participant (and parent/s of a minor) assumes and accepts full responsibility for participant for the inherent and other risks (both known and unknown and described above or otherwise) of these activities and for any injury, damage, death or other loss suffered by participant (and parent/s of a minor) resulting from those risks, including the risk of participant’s own 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 for myself and, if my child is a minor, for and on behalf of my participating minor child) agree as follows:

(1) to release and agree not to sue HMI, with respect to any and all claims, liabilities, suits or expenses (including attorneys’ fees and costs) (hereafter “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 HMI activities. I understand I agree here to waive all claim/s I or my child may have against HMI, bind my/my child’s estate and any family member/heir/other party bringing claim/s and agree that neither I, my child nor anyone acting on my or my child's behalf, will make a claim against HMI as a result of any injury, damage, death or other loss suffered by me/my child;

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Additional risks associated with international travel____________________________________________________________

Political unrest, terrorism or warfare; contact with unusual diseases or bacteria; thievery or abduction; primitive, inadequate or inaccessible medical facilities; additional delays in transport from a foreign country back to the U.S. for medical care; laws and legal systems in foreign countries that do not provide the same protections as the U.S. legal system. Note: Although HMI considers

current geo-political climates in choosing program locations, HMI personnel are not experts in assessing the likelihood of terrorist activity, political unrest, the need for vaccinations or other issues. The apprentice is responsible for conducting his or her own independent investigation through the U.S. State Department, U.S. Centers for Disease Control, World Health Organization or other sources.

Acknowledgement and Assumption of Risks & Release and Indemnity Agreement

Page 4 of 4

Please read and review this entire Document carefully!

(2) to defend and indemnify (“indemnify” meaning protect by reimbursement or payment) HMI, with respect to any and all claim/s: a) brought by or on behalf of me, my child, my spouse or other family member/s, or my/my child’s heir/s or estate for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or participation in HMI activities,; and/or, b) brought by a co-participant or any other person for any injury, damage, death or other loss to the extent caused by my/my child’s gross negligence, or willful, wanton or criminal misconduct, in the course of participating in HMI activities, or, brought by a medical care provider, insurer, or other third party as a result of medical care provided to me/my child, including transportation and evacuation costs,.

This Release and Indemnity Agreement includes claim/s of or resulting from HMI’s negligence (but not its gross negligence or willful or wanton misconduct), and includes claim/s for personal injury or wrongful death (including claim/s related to emergency, medical, drug and/or health issues, response, assessment or treatment), property damage, loss of consortium, breach of contract or warranty or any other claim.

Other Provisions: I (participant and parent/s of a minor participant) agree that Colorado substantive law (without regard to its “conflict of laws” rules) governs this Document, any dispute I/my child have with HMI and all other aspects of my/my child’s relationship with HMI, contractual or otherwise, and agree that any mediation, suit or other proceeding must be filed or entered into only in Lake County, Colorado. I will attempt to settle any dispute through mediation before a mutually acceptable Colorado mediator.

If any portion of this Document is deemed unlawful or unenforceable, it shall not affect the enforceability of the remaining provisions, and those remaining provisions shall continue in full force and effect. This Document is intended to be interpreted and enforced to the fullest extent allowed by law.

Participant and parent/s of a minor participant agree: I have carefully read, understand and voluntarily sign this Document and acknowledge that it shall be effective and legally binding upon me, my spouse, participating minor child and other children, and parent/s/participant’s other family members, heirs, executors, representatives, subrogees, assigns and estate. Participant must sign below. If participant is a minor (under 18 yrs. of age), one parent or legal guardian, or both parent/s, if available, must also sign below.

Participant Name (printed):_____________________________Participant Signature: ____________________________ Date: _______ Parent/Guardian Name (printed):________________________Parent/Guardian Signature: ________________________ Date: _______ 2

nd Parent/Guardian Name (printed): _____________________2

nd Parent/Guardian Signature: _____________________Date: _______

High Mountain Institute General Medical History & Information Form

Page 1 of 3 TO BE COMPLETED BY STUDENT or PARENT/S (if student is under 18)

The High Mountain Institute collects medical information to endeavor to provide more successful experiences and to assist in managing the risks faced by our students. HMI's programs vary greatly in environmental conditions, physical difficulty, and access to professional medical care. Please contact us if you have questions about these issues or the activities and risks associated with your specific program as you complete this form. HMI treats all personal medical information with some degree of confidentiality. Enrolled student medical information is shared with the faculty, apprentices and adjunct faculty who oversee the students on campus and in the field for a particular program.

Student Name HMI Program Today’s Date

Student’s DOB Age Gender

Parent/Guardian Contact Info OR Emergency Contact Info if over 18

2nd

Parent/2nd

Guardian Contact Info

Full Name Full Name

Day Phone Day Phone

Eve Phone Eve Phone

Cell Phone Cell Phone

E-Mail E-Mail

GENERAL HEALTH QUESTIONS: Please read the items in each column carefully and respond to each item (YES, NO or N/A –

not applicable) regarding any past or current medical issues or concerns regarding the condition/problem/illness/area listed:

Please select “YES” or “NO” to each item in this column: Please select YES, NO, or N/A for this column: YES NO N/A

ALLERGY and/or DIETARY RESTRICTIONS Addiction and/or regular use of alcohol or drugs CALL

Bee/insect stings, shellfish, iodine, nuts, dairy, other foods, pollen, medications, and any other known allergies. Dietary restrictions including medical, religious, or ethical. If “YES” complete the ALLERGY /DIETARY RESTRICTIONS Form

YES

NO

Altitude: Acute Mountain Sickness (AMS)

High Altitude Cerebral Edema (HACE) CALL

High Altitude Pulmonary Edema (HAPE) CALL

Asperger’s, Autism or PDD

Bleeding, Blood Disorders, Tuberculosis, Hepatitis

ATTENTION DEFICIT (HYPERACTIVITY) DISORDER Cancer

Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder, and other related issues or learning disorders If “YES” please complete the ADD/ADHD Form

YES

NO

Cardiovascular (heart and vessels) Abnormalities or Problems, including high blood pressure

Circulatory Problems

Cold Injuries

Dental Problems/Issues

MEDICATIONS Diabetes CALL

Prescription medications, over-the-counter medications, dietary supplements, herbal remedies, and any other medications If “YES” please complete the MEDICATIONS Form

YES

NO

Ear, Eye, Nose & Throat Infections/Issues/Problems

Eating Disorder (anorexia, bulimia, etc.)

Epilepsy or Other Seizure Disorders CALL

Fainting or Dizziness, chronic

MENTAL HEALTH ISSUES/ILLNESS Gastrointestinal Tract, Ulcers

Anxiety disorders, depression, past history of suicide attempt or ideation, past addiction to alcohol or drugs, self-abuse, or any other mental health issues If “YES” please complete the MENTAL HEALTH Form

YES

NO

Head Injuries, Concussions, Headaches

Heat Injuries/Illness

Hormonal &/or Thyroid

Hypertension

Kidney or Liver Disease or Issues

ORTHOPEDIC INJURIES Menstrual Cramps

Shoulder, arm, elbow, hand, neck, back, hips, leg, knee, ankle, foot, recurrent strains of particular muscles, recurrent sprains of particular joints, hernia, other musculoskeletal issues, and other athletic or orthopedic injuries If “YES” please complete the ORTHOPEDIC Form

YES

NO

Neurological Disorders

Pregnancy, current CALL

Reproductive Tract

Respiratory Tract, including Asthma

Skin Problems/Issues

For each “YES” item, please fully explain the history, current status, and note the treating physician’s name and phone number on the

next page

Sleepwalking

Sudden death under age 50 of family member CALL

Syncope with exertion (fainting during exercise) CALL

Tobacco regular use and/or addiction CALL

Urinary Tract

Vision or hearing issues or impairment

Other, including hospitalization in last 5 years (explain):

Call HMI immediately regarding any “YES” answer for the “ CALL” issues above.

High Mountain Institute General Medical History & Information Form

Page 2 of 3 TO BE COMPLETED BY STUDENT or PARENT/S (if student is under 18)

Have you been under the care of a physician in the last 12 months? If “Yes”, please explain why: ___________________________________

Considering the information you have provided above or otherwise, does the student have any condition/s (e.g. mental, physical, emotional) which might affect or limit his or her well-being, the well-being of others, or the student’s ability to engage in HMI activities?: Please include any adaptations or modifications appropriate or necessary.

Date of last tetanus immunization: ______________________________________ Do you have medical insurance (Circle one)? Yes No Medical Insurance Carrier: ____________________________________________ Policy/Group #: _____________________________________________________

Additional Notes: ________________________________________________________________________________

High Mountain Institute General Medical History & Information Form

Page 3 of 3 TO BE COMPLETED BY STUDENT or PARENT/S (if student is under 18

ATTENTION – SIGNATURE REQUIRED! One or both parent/s of the student, or the student if an adult (those 18 years of age or older), must sign below for both the Acknowledgment/Agreement and Medical Authorization:

ACKNOWLEDGEMENT/AGREEMENT To the best of my knowledge, this medical form and any supplemental medical information I submit (any supplemental information incorporated by this reference) contains accurate information. I understand the nature of HMI activities, and acknowledge that I can contact HMI should I have any questions about these activities or the associated physical, mental or emotional demands or other concerns. Other than any limitations described in this form (or in information submitted by the student's health care provider/s), the student agrees, and has permission from his or her parent/s if he or she is a minor, to participate in all HMI activities. I agree to contact HMI if any medical or health condition changes before the start of the HMI program. I understand that providing inaccurate medical or health information or falsifying medical or health information can create serious risks to the student or others, and/or can result in the student’s dismissal from the program. I understand the student’s final acceptance and participation in the program is contingent upon HMI representatives’ review of all forms, including this one. I understand that although HMI will review this information and may allow participation, HMI cannot anticipate or eliminate risks or complications posed by a student’s mental, physical, or emotional condition. I understand that emergency, medical, drug and/or health issues, response, assessment or treatment are included within the scope of – and expressly subject to the terms of – the HMI Acknowledgment and Assumption or Risks & Release and Indemnity Agreement. Please review that Document carefully in regard to the activities, risks and your responsibilities. Note: I consent here to allow HMI staff or its consulting health care providers to contact and communicate with the student’s health care provider/s listed in these forms about the student’s health and medical condition or care. HMI keeps and provides regular over-the-counter medications for minor illness (headaches, cramps, cold & flu, sore throat, etc.) and asks that students do not bring them. Signing this Acknowledgement/Agreement gives HMI permission to administer over-the-counter medications.

MEDICAL AUTHORIZATION: I authorize HMI staff, representatives and/or other medical personnel to obtain or provide medical care for me/my child, to transport me/my child to a medical facility, and/or to provide treatment (including, but not limited to hospitalization, medications, injections, anesthesia, or surgery) they consider necessary for my/my child’s health. I agree to the release (to or by HMI) of any records necessary for treatment, referral, billing, or insurance purposes. I agree that HMI has no responsibility for medical care provided to me/my child, and agree to pay all costs associated with this care, including but not limited to medical evacuation, travel, compensation and expenses for staff accompanying the student, medicine and treatment. This form may be photocopied for use in the field.

Student Name (printed): Student Signature: Date: Parent/Guardian Name (printed): Parent/Guardian Signature: Date: 2

nd Parent/Guardian Name (printed): 2

nd Parent/Guardian Signature: Date:

LAKE COUNTY BACKPACKING TRIP EQUIPMENT LIST:

Almost all of the equipment on this list can be borrowed for free from HMI. Casi todo el equipo necesario en esta lista se puede tomar prestado gratis de HMI.

However, if you have something at home that you think might work, please bring it with you on the first day (since you won't be able to return home to get it). If it works, that's great and if not, we'll store it while you're backpacking and can loan you something instead. Sin embargo, si tiene algo en casa de la lista de equipo, por favor, tráigalo el primer día. Si funciona, perfecto. Si no, puedes guardarlo en HMI durante el viaje y podemos prestarle algo para usar.

Please bring it all with you on the first day! !Por favor traiga todo el primer día!

In general, try not to bring cotton clothing (for example: wool socks are better than cotton socks, and fleece pants are better than cotton sweatpants. We recommend not wearing jeans). If cotton clothing gets wet it doesn't keep you warm and takes a very long time to dry. Also, it is important that you can wear all of your layers at the same time (for example: you will want to be able to wear your t-shirt, a long sleeved shirt, and a fleece jacket all at the same time). En general, no debe traer ropa de algodón (por ejemplo, calcetines de lana serían mejores que calcetines de algodón y pantalones de vellón serían mejores que sweatpants. Recomendamos que no use jeans.) Si la ropa de algodón se moja, no se mantiene caliente y tarda mucho tiempo para secarse. Además es importante que pueda usar todas sus capas al mismo tiempo (por ejemplo: va a querer poder usar su t-shirt, su camisa de mangas largas y su chaqueta de vellón al mismo tiempo.)

Please bring (or wear) these items with you on the first day. Por favor traiga o lleve todo con usted el primer día.

On the first day, please come dressed ready to go for a short day-hike. El primer día, por favor llega listo para una caminata corta.

There are a few items on this list that are in bold. These are personal items that you must bring with you from home. Algunos artículos en la lista están en negrita. Hay que traer estos artículos personales de la casa.

Storage

1 Large hiking backpack / mochila grande para caminar en el bosque

1 Small backpack / mochila pequeña

Sleeping

1 Sleeping bag (synthetic, rated to 0-20 degrees F) / bolsa de dormer

1 Full length foam pad (or Thermarest type air mattress) / colchon delgado de hule espuma para dormir

Feet

2 Socks (wool better than cotton) / calcetines de lana

2 Shoes (old running, tennis or sneakers to wear around camp) / zapatos usados atléticos, tenis usados

1 Hiking boots or high top basketball sneakers / botas para caminar en el bosque

Layers

1 Shorts (athletic shorts are best) / short atlético

1 T–shirt / camisa de manga corta

1 Hiking pants (athletic pants are great) / pantalones para caminar en el bosque (pantalones atléticos)

1 Long underwear (top and bottom) / ropa térmica de materiales sintéticos para uso debajo de la ropa

1 Warm fleece pants or sweatpants / pantalones de franela

1 Warm fleece or wool sweater or warm jacket / chamarra, chaqueta o suéter de franela

1 Rain jacket with hood / chamarra o chaqueta para la lluvia

1 Rain pants / pantalones para la lluvia

1 Warm hat / gorro calientito

1 Sun hat or baseball cap / sombrero de ala ancha

1 Sunglasses / lentes de sol, gafas de sol

Miscellaneous Important Personal Items

2 Water bottles (1 liter each) / botella de agua de 1 litro

1 Hot drink travel mug or small water bottle / botella de agua de ½ litro

1 Bowl (plastic, Tupperware with lid is perfect) / traste de plastico para sopa (Tupperware)

1 Spoon / cuchara

1 Headlamp or small flashlight / lámpara pequeña

1 Bandana / pañuelo de tela

3 Underwear (cotton is better than nylon, sports bras are good for women) / ropa interior

1 Toiletries, travel size (toothbrush, toothpaste, tampons or pads, brush) / artículos para hygiene personal

1 Lip balm (spf 15 or greater) / crema de cacao para los labios

1 Sunscreen (spf 15 or greater) / protector solar

1 Hand sanitizer (travel size) / gel desinfectante para manos

1 Towel / toalla

Miscellaneous Optional Personal Items

Opt Camera / cámara

Opt Journal/pen/pencil / cuaderno y lápiz

Opt Contacts w/ extra solution (if you wear them) / lentes de contacto y solución extra

Opt Extra glasses (if you wear them) / anteojos extra

Opt Watch / reloj

HMI Will Supply:

1 Bug spray (travel size) / repelente de mosquitos

THINGS NOT TO BRING (THIS MEANS PLEASE DO NOT BRING THEM!) / OBJETOS QUE NO SE PERMITEN Any computer equipment / equipo de computadora Cell phones/teléfonos celulares—if you need to contact someone, you can use an instructor's phone

or the HMI phones. Si necesitas comunicarse con alguien, puede usar el cellular de un instructor o los teléfonos de HMI.

If you have any questions, please contact Libbey Holewski of HMI (719-486-8200 ext 107; lholewski@hminet.org) or Abby Mortimer of Full Circle (719-486-2400 ext 15; girls@fullcircleleadville.org). Si tiene alguna pregunta por favor comuníquese con Abby Mortimer de Full Circle (719-486-2400 ext 15; girls@fullcircleleadville.org) o Libbey Holewski del High Mountain Institute (719-486-8200 ext 107; lholewski@hminet.org).