Westminster SCUBA Diving Global Program

Transcription

1 Westminster SCUBA Diving Global Program Providing students with the skills, knowledge, and opportunity to be life-long advocates for the world s oceans and the creatures that live in them. & UNEXSO Freeport, Bahamas July 16-21, 2017

2 Westminster SCUBA Diving Global Program Island Experience 2017 Please read the following Westminster SCUBA Diving Global Program course description and assess the student s ability to participate in the complete program. The Westminster SCUBA Diving Global Program focuses on providing students and their families with the skills, knowledge, and opportunity to be life-long advocates for the world s oceans and the creatures that live in them. This program, sanctioned by the Professional Association of Diving Instructors (PADI) will guide participants through gaining the necessary knowledge and skills to obtain lifetime SCUBA certification and participate in a one-week island immersion experience focused upon sustainability, marine research, education and reef conservation. Program Outline This 3-part program begins with meeting the pre-requisites of 14 years of age and demonstration of watermanship skills (10 min deep water tread, 200 yard free swim): Part 1- Classroom Training. Lectures in diving physics, physiology, equipment, environmental considerations, and dive tables will be delivered in a blended learning environment. Participants will use the PADI elearning online system to gain knowledge and demonstrate mastery of topics via the ebook, PADI Open Water Diver Manual, online videos, journal entries, and online assessments. Participants will demonstrate their understanding of theory and dive planning through selfassessments, knowledge reviews, and quizzes. Mastery of the T/F, multiple-choice, mix and match, and short answers will be documented as part of the diver s elearning record. Upon successful completion of the 5 units of study, the participant will complete a 20 question quick review with the instructor. Units of study will be completed in sequential order with the corresponding pool training. Part 2- Pool training. Participants will gain the knowledge and skill necessary to conduct themselves with competence underwater. A high emphasis is placed on safety and problem prevention. Emergency actions, rescue skills and dive planning are emphasized, along with practical application of diving skills in the pool. Divers Alert Network (DAN) will provide insurance for all students throughout their training experience. A total of 10 hour pool training sessions are required. Optional pool training sessions will be offered to ensure that participants who need more skill development or want to advance their development have the opportunity. Participants will selfreflect on progress through journal entry, which will include underwater video documentation of skill demonstration. Part 3- Open Water Dives (Island Experience). The open water dives will be completed during the summer trip, during the Island in Freeport, Bahamas in an open ocean environment. PADI SCUBA Diver Certification is granted for successful completion of all course requirements and at least four open-water dives. This week-long Island Experience adventure will allow participants to experience first-hand the community at Underwater Explorers Society (UNEXSO) in the Grand Bahamas and demonstrating their commitment to sustaining life on earth. It will include 3 unique activities: Activity 1- Open Water Dives. Two days will be devoted to conducting the four open-water dives necessary to obtain PADI Open Water Diver certification.

3 Activity 2- Advanced Diving Opportunity. Based on Captain s choice and weather conditions, a deep dive, cavern dive, and marine fish ID dive will be conducted. This opportunity is open to all divers. Activity 3- Learning Opportunity. In conjunction with UNEXSO, two unique marine dive experiences with sharks and dolphins will be provided for the participants. This opportunity is open to all divers. Program preparation and participation: Maintaining alertness, a cooperative positive attitude, and punctuality Being well-prepared, making positive contributions Follow the Westminster Honor Code Engaging in interaction with the community Follow the PADI Diving Guidelines for safe diving at all times Course Timeline Mid December-May 13. Classes online. Flexible, based on each participant s preferred pacing utilizing the PADI elearning online system to gain knowledge and demonstrate mastery of topics. Students are strongly encourage to complete the online class BEFORE the first pool session. Mid February-May 13. Pool sessions at Westminster. Wednesdays: 6:30 p.m to 8:30 p.m. A total of 10 hour pool training sessions are required (typically, two per month). Optional pool training sessions will be offered to ensure that participants who need more skill development or want to advance their development have the opportunity. July 16. Travel to FRO, Bahamas. Marina Tour, Rules, & Hotel Checkin July 17. Open Water Certification Dives #1 & #2. July 18. Open Water Certification Dives #3 & #4. July 19. Shark & Dolphin Presentation Sessions. Island Trip. July 20. Advanced Dives, Dolphin Presentation Session 2, Celebration & Wrap Up. July 21. Return to Atlanta, GA.

4 Cost of Trip Program Components WESTMINSTER STUDENT NON- CERTIFIED DIVER WESTMINSTER STUDENT CERTIFIED DIVER FAMILY MEMBER NON- CERTIFIED FAMILY MEMBER CERTIFIED DIVER FAMILY MEMBER (NON-DIVER) Professional Personal Dive Gear Dive Mask, Fins, Snorkel, Booties $90 Upgradeable $150, $200 Paid to Divers Supply of Marietta $90 Upgradeable $150, $200 Paid to Divers Supply of Marietta Course Material Westminster Crew Pack: Logbook, Electronic Dive Planner, C-Card $85 Official PADI materials paid to The Westminster Schools $85 Official PADI materials paid to The Westminster Schools Course Tuition PADI elearning Course $149 Official PADI online course fee paid to The Westminster Schools $149 Official PADI online course fee paid to The Westminster Schools Instructor Fee PADI Certified Instructor No Charge No Charge Must complete a mandatory pool session to demonstrate competency $100 $50 Must complete a mandatory pool session to demonstrate competency Travel Airfare to Freeport, Grand Bahamas Approximately $800 (Based on best fare at time of booking) Approximately $800 (Based on best fare at time of booking) Approximately $800 (Based on best fare at time of booking) Approximately $800 (Based on best fare at time of booking) Approximately $700 (Based on best fare at time of booking) Island Certification Experience Breakfast, Lodging, Project AWARE Activities, Boat Dives & Gear (for divers) $1,620 $1,620 $1,620 $1,620 $750 Prices the best possible current estimate; however, THE FINAL PRICE IS SUBJECT TO CHANGE, if the minimum number of participants is not reached. Lunches (est. $15/lunch) and Dinners (est. $45/meal) are not included. Personal spending money is additional (snacks, souvenirs). Estimate $250 for lunch/dinner and $100 for basic spending. Schedule SUN JULY 16 MON JULY 17 TUE JULY 18 WED JULY 19 THUR JULY 20 FRI JULY 21 Morning 7:30AM Depart for Dive Marina Depart for Dive Marina Depart for Dive Marina Depart for Dive Marina Early Depart to FPO Breakfast 7:45AM Breakfast Breakfast Breakfast Breakfast Check In 8:30 AM Cert Boat Dives 1 & 2 Cert Boat Dives 3 & 4 Dolphin 2 or Open Dive Open DIve 2-Tanks Lunch 12:30 PM Marina Marina Marina Marina Afternoon 2:00 PM Dive debrief & planning Dolphin Dive Group1 Optional Shark Dive Project AWARE activity Exploration 4:30 PM FPO Exploration time Dive debrief & certification Project AWARE activity Exploration time Dinner 6:00 PM Hotel Zorbas Dinner Dinner Dinner Evening 7:30 PM Tour of Dive Marina Packing & Rest Port Lucaya Market Place Night Off Celebration & Wrap Up

5 Grading and Credit This is a non-credit program. The American Council of Education (ACE) recommends college credit for the PADI (Professional Association of Diving Instructors) scuba diver course. Students seeking college credit can find more information here: Applying Apply here to be accepted into the program. You will get a confirmation when the application is received, and notified by Dec 31, 2016, if you have been accepted into the program. Once accepted into the program, each attendee must complete the following: 1. Emergency Contact Information- complete online by clicking here 2. PADI Liability Release & Assumption of Risk Agreement 3. PADI Standard Safe Diving Practices Statement of Understanding 4. PADI Medical Statement 5. Student Contract, Alcohol/Drug/Tobacco Policies 6. Upper School Policy for Prescription Medication on School Sponsored Trips 7. Full Disclosure of Conditions Before Arranging for Summer Travel 8. General Agreement/Release/Waiver 9. A clear, legible color photocopy of your updated passport* *A clear, legible photocopy of your updated passport photo and number. If you do not have a passport yet, you must start the process as soon as possible; include a copy of your completed and mailed passport application; a scanned image of your new passport photo and number to colleenglaude@westminster.net. Keep a copy of the passport number & photo for yourself once overseas--your parents should also keep a copy. Selection criteria Selection is based on strength of application and personal reflection/essay questions. Preference is given to non-certified students based on seniority. Important Dates Application Due: December 31, 2016 Acceptance received by: January 13, 2017 Turn in forms & passport/id copies: Feb 8, 2017 Gear fitting session: February 1, Turner Gym, 6:00 p.m. Pool Sessions begin Mid February, 6:30-8:30 p.m. (2 per month) First Payment of $400.00: March 1, 2017 Rest of the payment: June 1, 2017 Parents Meeting, 7:00 p.m., Turner Gym, July 12, 2017

6 (2) PADI Liability Release & Assumption of Risk Agreement Please read carefully and fill in all blanks before signing. LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT I,, hereby affirm that I am aware that skin and scuba diving have inherent risks which Participant Name may result in serious injury or death. I understand that diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or other hyperbaric/air expansion injury that require treatment in a recompression chamber. I further understand that the open water diving trips which are necessary for training and for certification may be conducted at a site that is remote, either by time or distance or both, from such a recompression chamber. I still choose to proceed with such instructional dives in spite of the possible absence of a recompression chamber in proximity to the dive site. I understand and agree that neither my instructor(s),, Colleen A. Glaude PADI OWSI# the facility through which I receive my instruction, _, The Westminster Schools, Atlanta, GA nor PADI Americas, Inc., nor its affiliate and sub- Facility Name sidiary corporations, nor any of their respective employees, officers, agents, contractors or assigns (hereinafter referred to as Released Parties ) may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur as a result of my participation in this diving program or as a result of the negligence of any party, including the Released Parties, whether passive or active. In consideration of being allowed to participate in this course (and optional Adventure Dive), hereinafter referred to as program, I hereby personally assume all risks of this program, whether foreseen or unforeseen, that may befall me while I am a participant in this program including, but not limited to, the academics, confined water and/or open water activities. I further release, exempt and hold harmless said program and Released Parties from any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in this program including both claims arising during the program or after I receive my certification. I also understand that skin diving and scuba diving are physically strenuous activities and that I will be exerting myself during this program, and that if I am injured as a result of heart attack, panic, hyperventilation, drowning or any other cause, that I expressly assume the risk of said injuries and that I will not hold the Released Parties responsible for the same. I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I understand the terms herein are contractual and not a mere recital, and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the un-enforceable provision had never been contained herein. I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns, or beneficiaries may have to sue the Released Parties resulting from my death. I further represent I have the authority to do so and that my heirs, assigns, or beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties. I,, BY THIS INSTRUMENT AGREE TO EXEMPT AND RELEASE MY INSTRUCTORS, Participant Name, Colleen A. Glaude PADI OWSI# THE FACILITY THROUGH WHICH I RECEIVE MY INSTRUCTION,, The Westminster Schools, Atlanta, GA AND PADI AMERICAS, INC. AND ALL RELATED ENTITIES AS Facility Name DEFINED ABOVE, FROM ALL LIABILITY OR RESPONSIBILITY WHATSOEVER FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH HOWEVER CAUSED, INCLUDING BUT NOT LIMITED TO THE NEGLIGENCE OF THE RELEASED PARTIES, WHETHER PASSIVE OR ACTIVE. I HAVE FULLY INFORMED MYSELF AND MY HEIRS OF THE CONTENTS OF THIS LIABILITY RELEASE AND ASSUMPTION OF RISK AGREEMENT BY READING IT BEFORE I SIGNED IT ON BEHALF OF MYSELF AND MY HEIRS. Participant Signature Date (Day/Month/Year) Signature of Parent of Guardian (where applicable) Date (Day/Month/Year) PRODUCT NO (Rev. 3/06) Version 4.02 PADI 2006

7 (3) PADI Standard Safe Diving Practices Statement of Understanding STANDARD SAFE DIVING PRACTICES STATEMENT OF UNDERSTANDING Please read carefully before signing. This is a statement in which you are informed of the established safe diving practices for skin and scuba diving. These practices have been compiled for your review and acknowledgement and are intended to increase your comfort and safety in diving. Your signature on this statement is required as proof that you are aware of these safe diving practices. Read and discuss the statement prior to signing it. If you are a minor, this form must also be signed by a parent or guardian. I,, understand that as a diver I should: (Print Name) 1. Maintain good mental and physical fitness for diving. Avoid being under the influence of alcohol or dangerous drugs when diving. Keep proficient in diving skills, striving to increase them through continuing education and reviewing them in controlled conditions after a period of diving inactivity, and refer to my course materials to stay current and refresh myself on important information. 2. Be familiar with my dive sites. If not, obtain a formal diving orientation from a knowledgeable, local source. If diving conditions are worse than those in which I am experienced, postpone diving or select an alternate site with better conditions. Engage only in diving activities consistent with my training and experience. Do not engage in cave or technical diving unless specifically trained to do so. 3. Use complete, well-maintained, reliable equipment with which I am familiar; and inspect it for correct fit and function prior to each dive. Deny use of my equipment to uncertified divers. Always have a buoyancy control device and submersible pressure gauge when scuba diving. Recognize the desirability of an alternate air source and a low-pressure buoyancy control inflation system. 4. Listen carefully to dive briefings and directions and respect the advice of those supervising my diving activities. Recognize that additional training is recommended for participation in specialty diving activities, in other geographic areas and after periods of inactivity that exceed six months. 5. Adhere to the buddy system throughout every dive. Plan dives including communications, procedures for reuniting in case of separation and emergency procedures with my buddy. 6. Be proficient in dive table usage. Make all dives no decompression dives and allow a margin of safety. Have a means to monitor depth and time underwater. Limit maximum depth to my level of training and experience. Ascend at a rate of not more than 18 metres/60 feet per minute. Be a SAFE diver Slowly Ascend From Every dive. Make a safety stop as an added precaution, usually at 5 metres/15 feet for three minutes or longer. 7. Maintain proper buoyancy. Adjust weighting at the surface for neutral buoyancy with no air in my buoyancy control device. Maintain neutral buoyancy while underwater. Be buoyant for surface swimming and resting. Have weights clear for easy removal, and establish buoyancy when in distress while diving. 8. Breathe properly for diving. Never breath-hold or skip-breathe when breathing compressed air, and avoid excessive hyperventilation when breath-hold diving. Avoid overexertion while in and underwater and dive within my limitations. 9. Use a boat, float or other surface support station, whenever feasible. 10. Know and obey local dive laws and regulations, including fish and game and dive flag laws. I have read the above statements and have had any questions answered to my satisfaction. I understand the importance and purposes of these established practices. I recognize they are for my own safety and well-being, and that failure to adhere to them can place me in jeopardy when diving. Participant s Signature Signature of Parent or Guardian (where applicable) Date (Day/Month/Year) Date (Day/Month/Year) PRODUCT NO (Rev. 11/05) Version 1.05 PADI 2005

8 (4) PADI Medical Statement Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during the scuba training program. Your signature on this statement is required for you to participate in the scuba training program offered by and Colleen A. Glaude PADI OWSI# Instructor The Westminster Schools located in the Facility city of, state/province of. Read this statement prior to signing it. You must complete this Medical Statement, which includes the medical questionnaire section, to enroll in the scuba training program. If you are a minor, you must have this Statement signed by a parent or guardian. Diving is an exciting and demanding activity. When performed correctly, applying correct techniques, it is relatively safe. When To the Participant: The purpose of this Medical Questionnaire is to find out if you should be examined by your doctor before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that there is a preexisting condition that may affect your safety while diving and you must seek the advice of your physician prior to engaging in dive activities. Atlanta GA Divers Medical Questionnaire Could you be pregnant, or are you attempting to become pregnant? Are you presently taking prescription medications? (with the exception of birth control or anti-malarial) Are you over 45 years of age and can answer YES to one or more of the following? currently smoke a pipe, cigars or cigarettes have a high cholesterol level have a family history of heart attack or stroke are currently receiving medical care high blood pressure diabetes mellitus, even if controlled by diet alone Have you ever had or do you currently have Asthma, or wheezing with breathing, or wheezing with exercise? Frequent or severe attacks of hayfever or allergy? Frequent colds, sinusitis or bronchitis? Any form of lung disease? Pneumothorax (collapsed lung)? Other chest disease or chest surgery? Behavioral health, mental or psychological problems (Panic attack, fear of closed or open spaces)? Epilepsy, seizures, convulsions or take medications to prevent them? Recurring complicated migraine headaches or take medications to prevent them? Blackouts or fainting (full/partial loss of consciousness)? Frequent or severe suffering from motion sickness (seasick, carsick, etc.)? MEDICAL STATEMENT Participant Record (Confidential Information) established safety procedures are not followed, however, there are increased risks. To scuba dive safely, you should not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with coronary disease, a current cold or congestion, epilepsy, a severe medical problem or who is under the influence of alcohol or drugs should not dive. If you have asthma, heart disease, other chronic medical conditions or you are taking medications on a regular basis, you should consult your doctor and the instructor before participating in this program, and on a regular basis thereafter upon completion. You will also learn from the instructor the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use under direct supervision of a qualified instructor to use it safely. If you have any additional questions regarding this Medical Statement or the Medical Questionnaire section, review them with your instructor before signing. Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. Your instructor will supply you with an RSTC Medical Statement and Guidelines for Recreational Scuba Diver s Physical Examination to take to your physician. Dysentery or dehydration requiring medical intervention? Any dive accidents or decompression sickness? Inability to perform moderate exercise (example: walk 1.6 km/one mile within 12 mins.)? Head injury with loss of consciousness in the past five years? Recurrent back problems? Back or spinal surgery? Diabetes? Back, arm or leg problems following surgery, injury or fracture? High blood pressure or take medicine to control blood pressure? Heart disease? Heart attack? Angina, heart surgery or blood vessel surgery? Sinus surgery? Ear disease or surgery, hearing loss or problems with balance? Recurrent ear problems? Bleeding or other blood disorders? Hernia? Ulcers or ulcer surgery? A colostomy or ileostomy? Recreational drug use or treatment for, or alcoholism in the past five years? The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition. Signature Date Signature of Parent or Guardian Date PRODUCT NO (Rev. 06/07) Ver PADI 1989, 1990, 1998, 2001, 2007 Page 1 of 6 Recreational Scuba Training Council, Inc. 1989, 1990, 1998, 2001, 2007

9 (4 Continued) PADI Medical Statement- Page 2 STUDENT Please print legibly. Name Birth Date _ Age First Initial Last Day/Month/Year Mailing Address _ City State/Province/Region Country Zip/Postal Code Home Phone ( ) Business Phone ( ) FAX Name and address of your family physician Physician Clinic/Hospital _ Address Date of last physical examination _ Name of examiner Clinic/Hospital Address Phone ( ) Were you ever required to have a physical for diving? Yes No If so, when? PHYSICIAN <NOT REQUIRED UNLESS YOU ANSWERED YES TO THE QUESTIONS ON THE PREVIOUS PAGE> This person applying for training or is presently certified to engage in scuba (self-contained underwater breathing apparatus) diving. Your opinion of the applicant s medical fitness for scuba diving is requested. There are guidelines attached for your information and reference. Physician s Impression I find no medical conditions that I consider incompatible with diving. I am unable to recommend this individual for diving. Remarks Date Physician s Signature or Legal Representative of Medical Practitioner Day/Month/Year Physician Clinic/Hospital_ Address Phone ( ) Page 2 of 6

10 (5) Student Contract, Alcohol/Drug/Tobacco Policies Westminster SCUBA Diving Program Island Experience 2017 Student Contract I (print your full name as it appears on your passport on this line) will participate in this school-sanctioned trip, and I will adhere to all the rules of conduct as stated in the Westminster Student Handbook, and especially on my honor, I pledge the following: Mindful of the dangers to myself and others around me, I will not drink any alcoholic beverage while overseas; I will faithfully follow the Westminster Drug and Alcohol Policy while overseas; Mindful of my own integrity and the integrity of others, I will not partake in mixed room visitation in any fashion while overseas; Understanding the importance of my role as a representative of the United States, as well as Westminster and my family, I will follow the dress code established by Westminster and The Island School; Carefully considering the nature of this course and especially the trip overseas, I will be punctual at all times, including attending school, and departure times; I will attend and actively participate in all classes and activities while abroad; Finally, as a representative of the Westminster community, my behavior will exceed the expectations behind this program, one that involves consistently treating those around me as I desire to be treated. Student Signature Date Signature of Both Parents: Date Date Westminster SCUBA Diving Program Island Experience 2017 I (student name) understand Westminster s alcohol/drug/tobacco policies and agree to adhere to them while in the Bahamas and while in transit. I also understand that I will be sent home the first time I violate these policies, that no second chances will be given. My family and I will incur related travel expenses. These may include the cost of changing my return ticket to the US and the cost of transporting me to RDS Bahamas and the accompanying chaperone back to Atlanta, GA. (Student signature) (Date) (Parent signature) (Date)

11 (6) Upper School Policy for Prescription Medication on School Sponsored Trips THE WESTMINSTER SCHOOLS Upper School Policy for Prescription Medication on School Sponsored Trips All prescription medication must be sent in the original prescription bottle identifying the student s name, medication name, dosage and directions. Medications for ADD/ADHD must be held and dispensed by an adult chaperone, otherwise students may self administer prescribed medication. Narcotic pain medications are not permitted on school sponsored trips. Name of Student (please print) Name of Parent (please print) I have read and accept the above policy Date Parent Signature Parents, please list below any medication that your student will be carrying on this trip.

12 (7) Full Disclosure of Conditions Before Arranging for Summer Travel (this information will be con=idential) Before arranging for students to attend a Westminster summer travel program (Westminster in Bahamas in this case), parents and students must provide or authorize the release of any information regarding counseling needs, health problems, psychological conditions, and/or drug alcohol use. Parents and students acknowledge that this trip represents unique challenges and that, except for any information provided or released pursuant to the preceding sentence, there is no indication of any condition whatsoever that prohibits full participation in the program. Please list below any contact this student has had within the last twelve months with any physician or mental health professional (including psychiatrist, psychologist, counselor, or substance abuse treatment received). Medical History Does the applicant currently have or have a history of: 1. Respiratory problems Yes No 2. Asthma Yes No If yes, severe? Yes No, Treatment: 3. Gastrointestinal disturbances Yes No 4. Diabetes Yes No 5. Bleeding, DVT (deep vein thrombosis or blood disorders) Yes No 6. Hepatitis or other liver disease Yes No 7. Neurological problems. Seizures. Epilepsy. Yes No 8. Dizziness or fainting episodes Yes No 9. Migraines Yes No 10. Any disease Yes No 11. Hypertension Yes No 12. Cardiac problems Yes No 13. Muscle/Skeletal Injuries/Fractures Yes No 14. Head Injury Yes No 15. Allergies Yes No If yes, is allergy life-threatening? Yes No EpiPen prescribed for student? Yes No Reaction symptoms/treatment: Medications Is he/she allergic to any medications? If yes, please list: Please list prescription or non-prescription medications this student will be taking during the expedition. Medication Dosage Side Effects/Restrictions For what condition? Personal History (counseling/psychiatric/learning Disabilities) 1. Has he/she had treatment, counseling or hospitalization with a mental health professional? Yes No 2. Is he/she currently in treatment or counseling? Yes No 3. Reasons for treatment or counseling? (Please comment on any yes responses) Suicide attempt Yes No Self-Injurious behavior Yes No Substance abuse/chemical dependency Yes No Eating disorder (anorexia/bulimia) Yes No Academic Yes No ADD/ADHD Yes No Family issues/divorce Yes No Depression Yes No Anxiety Yes No Other Yes No Please provide specieic dates and details of counseling and medications that were prescribed: Signing below indicates full agreement to disclose such conditions, or that no such conditions exist to require disclosure. Student Name & Signature: Date: Parent or Guardian Signature: _ Date:

13 (8) THE WESTMINSTER SCHOOLS GENERAL AGREEMENT/RELEASE/WAIVER STUDENT ACTIVITY My child,, has been given the opportunity to participate in a school trip to on, 20, which is being made available to students of The Westminster Schools, Inc. In consideration of my child being allowed to participate in this trip on the date(s) and for the period of time specified below: 1.I give my express permission for my child to participate fully in said trip; 2.I assume all risks of participation in said trip, including any risk associated with any special medical needs or conditions of my child*; 3.I authorize,, and, (an) adult(s) who will participate in said trip, to obtain on behalf of my child, at my expense, any necessary emergency medical services which may be required at any time during said trip; 4.My child and I hereby release and hold harmless The Westminster Schools, Inc., and any individual officer, employee, trustee, agent, or representative of The Westminster Schools, Inc., against any and all claims, actions, demands, liabilities, and damages with respect to any injury to person, regardless of severity, and/or loss of or damage to property of any type relating to or arising out of any activities or occurrences on said trip, except to the extent that such injury to person and/or loss of or damage to property results from a grossly negligent, intentional, or malicious act, failure to act, or omission by The Westminster Schools, Inc., or any individual officer, employee, trustee, agent, or representative of The Westminster Schools, Inc.; in addition, my child and I hereby agree to indemnify The Westminster Schools, Inc., and any individual officer, employee, trustee, agent, or representative of The Westminster Schools, Inc., against any and all claims, actions, demands, liabilities, damages, and expenses, including reasonable attorney s fees, with respect to any injury to my child s person, regardless of severity, and/or loss of or damage to my child s property of any type relating to or arising out of any activities or occurrences on said trip, except to the extent that such injury to person and/or loss of or damage to property results from a grossly negligent, intentional, or malicious act, failure to act, or omission by The Westminster Schools, Inc., or any individual officer, employee, trustee, agent, or representative of The Westminster Schools, Inc.; and 5.My child and I further hereby agree to indemnify The Westminster Schools, Inc., and any individual officer, employee, trustee, agent, or representative of The Westminster Schools, Inc., against any and all claims, actions, demands, liabilities, damages, and expenses, including reasonable attorney s fees, with respect to any injury to person, regardless of severity, and/or loss of or damage to property of any type relating to or arising out of any activities or occurrences on said trip and caused, either directly or indirectly, by my child. *NOTE: Special medical needs, allergies, or conditions of my child include. I have made appropriate arrangements regarding such medical needs or conditions. I am sending my child s injectable epinephrine (EpiPen) and/or inhaler if prescribed by an MD. I give permission for the trip chaperone to administer over the counter medications such as Tylenol (acetaminophen), Advil (ibuprofen), Benadryl (diphenhydramine) or TUMS to my child if needed. Yes No (Please initial). My medical insurance company is:. My medical insurance policy number is:. My phone number during the time that my child will be on this trip is:. I HAVE READ THIS AGREEMENT/RELEASE/WAIVER CAREFULLY AND UNDERSTAND THE CONTENTS. Activities Include SCUBA Diving** DateDate(s) of Activity: July 16-21, 2017 Parent or Legal Guardian s Signature 1 Date Parent or Legal Guardian s Signature 2 Date _ Student s Signature Revised _ Date **Additional activities may be attached by the school sponsor