Gumboot Camp 2017
July 31st-August 4th

Harborview Elementary

Juneau families with Alaska Native children are invited to sign up for Gumboot Camp. This preschool program uses culture and place to prepare four and five-year-old children for kindergarten. Students will sing, dance, drum, hear stories, and practice Lingit; as well as play outside, sort, paint, go to the beach (Saturday), and explore sea life.

Student Information
Student Last Name:
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Student First Name:
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Gender:
Mailing Address:
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Physical Address:
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Date of Birth:
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Age:
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The participant is a shareholder of:
Or is a lineal descendent of:
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Who is their:
And a shareholder of:
Tribal Affiliation:
Degree of Indian Blood:
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I'm interested in registering my child for the:
My child attended preschool/Head Start
Which preschool did they attend?
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Is your child signed up for Baby Raven Reads?
Parent/Guardian (1) Information
Name:
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Relationship to Participant:
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Physical Address:
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Mailing Address:
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Email Address:
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Home Phone:
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Cell Phone:
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Work Phone:
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Parent Guardian (2) Information
Name:
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Relationship to Participant:
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Physical Address:
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Mailing Address:
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Email Address:
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Home Phone:
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Cell Phone:
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Emergency Contact Information (other than parent/guardian)
Name:
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Cell Phone:
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Work Phone:
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Relationship:
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Agreement and Consent for Treatment
By typing my name below I certify that I, the undersigned parent or guardian, hereby consent to and authorize the administration of all needed medicines, performance of needed surgical treatment, and the administration of any anesthetic which is necessary in the opinion of the attending physician, and advisable in the event of medical emergencies regarding my son, daughter or dependent. It is understood that efforts shall be made to contact the undersigned prior to rendering emergency treatment to the patient.
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Student's insurance company:
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Membership Number:
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ANS/PHS Health Card ID Number:
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Policy Number:
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Medical Information
Allergies (food/medicine/environmental):
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Medications (list all prescribed or over-the-counter medications taken routinely, including dosage and frequency):
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Chronic Illnesses (diabetes, epilepsy, asthma, etc.):
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Injuries/Hospitalization (list any injuries/hospitalization within the last two years and give information as to when the injuries occurred, the extent of the injury, and if fully recovered):
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Physical condition (describe any physical conditions that might limit or prevent participation in certain activities. Additionally describe special accommodations which may be necessary to support your child):
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Parent/Guardian Permission to attend Gumboot Camp
I hereby give my child/dependent permission to: * Participate in Gumboot Camp, July 31st through August 4th, 2016 * Participate in physical activities * Participate in Tlingit and/or Haida language activities * Be transported to the nearest health facility in case of emergency.
Photo Release
I give permission for Sealaska Heritage to include my child's name, pictures, voice and work in news stories, and in educational, promotional, and cultural materials.
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Sealaska Heritage Institute, its officers, employees, and agents from liability from any and all claims including the negligence of Sealaska Heritage, its officers, employees and agents, resulting in personal injury, accidents or illness (including death) to my child/dependent, and property loss arising from, but not limited to, participation in the Gumboot Camp (hereinafter, The Activity).

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Trustees of Sealaska Heritage and the Juneau School District from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Alaska and that if any portion thereof is held invalid, it is agreed that the balance shall notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability assumption of risk and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be complete and unconditional release of all liability to the greatest extent allowed by law.

By typing your name in the box below, you are effectively providing your signature, indicating that you agree with the Waiver of Liability, Assumption of Risk, and Indemnity Agreement
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By typing your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
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Notes:
Please submit a photo of your child to lavina.vansickle@sealaska.com or mail to Sealaska Heritage (Gumboot Camp) 105 S. Seward St. Suite 201, Juneau, AK 99801. We'll be using the photos to label coat hooks, cubbies, and for a daily sign-in activity and it would be great to have everything ready for the first day of camp.
Parent Orientation
Mark your calendars for Sunday, July 30th for a parent orientation. We'll be discussing what to expect in kindergarten and during gumboot camp.
Gumboot Picnic
A potluck picnic is scheduled for Saturday, August 5th from 12-1:30.
Mini Parent Presentation
On Friday students will sing and drum for parents. 12-12:15 for kindergartners and 4:30-4:45 for 4-year-old students. We'll present as a whole group on Saturday, the 5th at the picnic (location to be determined).
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