Pali Chaperone Form for Portola HGM Group

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Please fill out this commitment form if you would like to be considered as a chaperone for the Portola HGM Group trip to the Pali Institute in Running Springs during the weekend of May 13-15, 2022. Please complete this form by Wednesday December 8, 2021

The total cost is $250. If selected, the full non-refundable fee is due Wednesday December 15, 2021. You will be invoiced via PayPal a few days prior to the due date.
Please contact portolhgmpa@gmail.com if you need an alternative payment system.

Information about the camp can be found at: https://www.paliinstitute.com/
and in this slideshow: https://docs.google.com/presentation/d/1b59aQdk0Bitl5q9sHw7dLMRecjHIKuUMb9ooc2L4ZYc/edit?usp=sharing

Email *

Chaperone's Name *

Relationship to Student *

Parent

Portola Teacher/Administratro

Other:

Child's Name *

Chaperone's gender (for purpose of room assignment) *

Female

Male

Parent's phone number *

Emergency contact phone number(s) *

I acknowledge that my total payment of $250 for this Pali Institute group trip is NON-REFUNDABLE. *

Yes

Required

I acknowledge that transportation to Pali Institute leaves on Friday May 13, 2022 3pm and returns Sunday May 15, 2022 around 3:30pm. *

Yes

Required

I plan on taking the following transportation to/from Pali *

Bus with the students (price included in the fee)

Providing my own transportation

I acknowledge that there is a risk for contracting COVID-19 and I accept that risk. I agree to take a COVID-19 PCR test 72 hours prior to departure for my child (and wait for negative results). Additionally, I consent to any additional testing, including rapid COVID testing per Pali Institute policies. I agree to comply with Pali COVID-19 policies, including wearing masks. *

Yes

COVID-19 VACCINATION STATUS: Are you fully vaccinated against COVID-19? *

Yes

Planning to be fully vaccinated before the Pali trip

I understand that my duties as chaperone will include supervising a group of students (other than my own child) during the bus rides to/from Pali, as well as supervising some daytime activities at Pali. *

Yes

Required

I have special skills or certification *

CPR certified

ACLS or PALS certified

Medical Training (please specify below)

Science Training (please specify below)

Outdoor or Adventuring expertise (please specify below)

Teaching experience

Other:

Required

Explain any special skills or certification not specified in previous question

CABIN REQUEST: Please list up to 4 people you’d like to bunk with at PALI CAMP. We will make every effort to place the chaperone with another chaperone that they’ve requested. However, we cannot guarantee rooming situations. If there is a chaperone with whom you feel you cannot bunk, please let us know. All requests of this nature will be kept strictly confidential and will be discarded after the field trip.

Questions or Comments

A copy of your responses will be emailed to the address you provided.

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