Paperwork Packet ECS Intermediate Aftercare 2022-2023

Step 1 of 4

Child Name(Required)

First Last

Parent Name(Required)

Parent/Guardian completing this form

First Last

Parent Cell Phone Number(Required)

Parent Email(Required)

Enter Email Confirm Email

Emergency Contacts

Emergency Contact No. 1(Required)

First Last

Emergency Contact No. 1 Relationship to Child(Required)

Parent, relative, family friend, etc.

Emergency Contact No. 1 Phone Number(Required)

Emergency Contact No. 2(Required)

First Last

Emergency Contact No. 2 Relationship to Child(Required)

Emergency Contact No. 2 Phone Number(Required)

Emergency Contact No. 3(Required)

First Last

Emergency Contact No. 3 Relationship to Child(Required)

Emergency Contact No. 3 Phone Number(Required)

Student Contract

At Venture Outdoors, we strive to create meaningful and healthful experiences for children in the outdoors. In order to do so, we foster an environment where safety and wellbeing are of utmost importance. Please review and discuss the following guidelines with your child prior to the program. We will review this contract during the program and have students sign their understanding and agreement.

Behavior Guidelines(Required)

We understand and agree to the Behavior Guidelines.

I will treat myself, others, and equipment with respect.

I will speak highly of my fellow peers and Venture Outdoors staff.

I will keep my hands to myself.

I will set a positive example for others because I am a role model.

I will always remain with my group and Venture Outdoors staff at all times.

I will ask Venture Outdoors staff for their permission to use the restroom, get a drink of water, or go elsewhere.

I agree to accept the instructions that are given to me by Venture Outdoors staff and follow them the first time.

Conduct Violation(Required)

We understand and agree to the Conduct Violation Code.

If I act in such a way that does not follow the behavior guidelines, I understand that there may be consequences for my actions, including verbal warnings, parental contact, or suspension/dismissal from the program. My parent may need to come pick me up from the program in the event that I need to be sent home in the middle of a program.

I will seek to understand why I acted the way I did and work with Venture Outdoors staff to make better behavior choices.

Parent Signature(Required)

We agree to the Behavior Guidelines and Conduct Violation Policy.

As a parent, I have read and understand this conduct contract. I have discussed these expectations with my child, who has agreed to follow them while in the program. I understand that I will not receive a refund mid-month if my child is suspended/dismissed from the program for violation of this contract.

Today's Date(Required)

Parent Signature(Required)

Program Evaluation Surveys

In order to assure that our program is of high quality and has a positive impact on your child, the program engages in ongoing evaluation and quality improvement efforts. This year, we are using an evaluation platform called "Hello Insight", which will survey your child at the beginning and end of the program. Read more below.

Consent

I have received and read this information.

Because your child participates in a Venture Outdoors program, they will be invited to fill out an online or paper survey at the beginning and end of each program cycle. These surveys measure the impact of the program on your child’s development and capture your child’s experiences within the program, allowing us to make critical improvements to meet their needs. All youth involved in the Venture Outdoors program will be invited to participate in this survey.

How will your child participate in the survey?

The surveys take about 20 minutes to fill out and will typically occur during normal program hours when the program meets. Your child will be invited to complete the survey in a group setting online or on paper, or receive an email or text message with a link to the survey to complete the survey on their own.

Participation is completely voluntary. You and your child have the right to terminate their participation at any time or to refuse their participation entirely without jeopardy to their status in the program. None of the activities will interfere with your child’s instructional time or affect their academic grades.

What are the benefits to taking the survey?

Your child will become more reflective about their skills and behaviors. Reflection is a key developmental skill that has been shown to lead to a wide-range of benefits for young people.

Additionally, as the adult staff learn more about your child’s interests and experiences in the program, they will be able to tailor activities to meet their needs.

Are there any risks or discomforts in taking the survey?

Risks are minimal to none for involvement in this study. However, your child may feel emotionally uneasy when asked to make judgments about themself and the program.

How is my child’s confidentiality protected?

All information obtained from your child on the survey will be kept confidential and may be used by staff to increase the quality of the program. Program managers, and possibly external evaluators, will also have access to the data so that they can continue to improve the program and support your child’s individual needs.

All data are gathered and analyzed through an online platform called Hello Insight. Your child’s name will not be associated with data in Hello Insight. Data within this platform are kept confidential in a secure database. Hello Insight will never use your child’s name for any reason related to this data, and all data displayed through this system will highlight combined or group results.

Who do I contact if I have questions about the survey?

If you have questions regarding this process or the surveys themselves, you may contact Mandy Revak, Venture Outdoors, at 412-255-0564 x238. You may also contact Hello Insight at support@helloinsight.org.

I agree to allow my child to participate in filling out surveys within this program.(Required)

Yes

Acknowledgement & Assumption of Risk Form

Consent(Required)

I will complete an Acknowledgment & Assumption for Risk for my child.

In addition to this paperwork packet, you must complete a Venture Outdoors Acknowledgement & Assumption of Risk Form for your child. Venture Outdoors staff will send this form to you to complete via a digital link.

	Yes	No
Asthma or other respiratory problems
Gastrointestinal disturbances
Diabetes
High blood pressure
Bleeding or blood abnormalities
Neurological problems or epilepsy
Dizziness or fainting episodes
Migraines
Heart problems
Disorders of urinary or reproductive tract
Knee, hip or ankle injuries and/or surgeries
Shoulder, arm, or back injuries and/or surgeries
Head injury
Child greatly affected by heat
Child gets cold easily
Stroke

	Yes	No
Allergic to bee stings or insect bites?
Any other allergies, such as food, medication or seasonal?
Will child carry medication for allergies?
Does child have special dietary needs, such as vegan/vegetarian?
Does child have muscle spasms?
Is child taking medication? If Yes, explain below.

	Yes	No
Does your child have a disability?
Does your child have a mobility impairment?
Is your child sensitive to sights, sounds or other sensations?
Has your child ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
Has your child ever been treated for emotional or behavioral difficulties or an eating disorder?
Has your child experienced a significant life event that continues to affect the child's life?
Is your child comfortable with water?

Paperwork Packet ECS Intermediate Aftercare 2022-2023

Paperwork Packet for Venture Outdoors Aftercare @ ECS 2022-2023

Emergency Contacts

Student Contract

Insurance Information

Child Medical Information & History

Program Evaluation Surveys

Acknowledgement & Assumption of Risk Form