Parent/Guardian Permission Slip

5th Annual Inter-Tribal Environmental Youth Campout
June 22-26, 2015
Fort Bragg, CA
Parent/Guardian Permission Slip
*PLEASE FILL OUT 1 FORM FOR EACH CHILD*
I, ________________________, hereby give my consent for my child to participate in the 5th Annual
Inter-Tribal Environmental Youth Campout on June 22-26, 2015, located at 20801 N. Hwy 1 Ft Bragg,
CA. This youth camp is intended for children between the ages of 8-17 years of age.
I agree that my child, _______________________________, is under the authority of the
_________________________ (Tribe) for the duration of the campout. I understand that if my child does
not follow instructions of the camp chaperones or fails to abide by the rules of conduct, he/she shall not
have the privilege of participating in the future campouts.
To ensure the safety of all attendees, the organizers and Tribal departmental staff of the campout expect
the following from youth participants:
1. Unacceptable behavior will not be tolerated, this includes but may not be limited to: bullying;
fighting; violence; sexual activity; personal and/or on-going verbal abuse; use of profanity,
use of alcohol, tobacco or illegal drugs; failure to follow safety guidelines; failure to follow
directions of the organizers, Tribal departmental staff and chaperones; leaving the
group/campsite without permission; and/or any act that may jeopardize the safety of your
child or others.
2. Youth are required to participate in activities that are scheduled; cooperate with organizers,
Tribal departmental staff and chaperones as well as other youth in attendance; Keep in mind
that all children should be representing their Tribe in a positive and respectful manner.
3. Youth are prohibited to carry any electronic devices (examples: cell phones, ipod, and mp3)
during the campout. The idea is to connect to the land and learn. Organizers, Tribal
departmental staff, and chaperones will maintain cell phones during Campout except for
times approved for use.
I, ________________________, expressly relieve and hold harmless the ________________________
(Tribe), staff, and other responsible adult from and against any and all liability or claims arising from
injury or damage suffered or incurred by my child or our property, as may be the result of acts, conduct,
or behavior or omission of my child or other persons, while at this campout.
_____________________________________
___________________
Parent/Guardian Name (print)
Date
_____________________________________
____________________
Parent/Guardian signature
Contact Phone Number
*In case of emergency, please list family members to contact
_____________________________
____________________
Emergency Contact Name
Contact Phone Number
Please return completed application back to your Tribe’s Campout Coordinator
For questions in regards to the Inter-Tribal Environmental Youth Campout, location and other logistics, please contact Theo Whitehurst,
Environmental Technician, Potter Valley Tribe at 707-462-1213 or [email protected].
.