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Enrollment Packet

 

PIVOT ADVENTURE COMPANY, LLC
ACKNOWLEDGMENT OF RISK, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT
READ CAREFULLY BEFORE SIGNING – THIS LIMITS PIVOT’S LIABILITY

I, on behalf of myself and my child (collectively referred to as “I”, “my”, or “me”) have voluntarily chosen to participate in recreational activities, including but not limited to indoor and outdoor rock climbing, ropes course and challenge course activities, hiking, snowshoeing, mountain biking, cross-country and downhill skiing, snowboarding, and travel associated with these activities (collectively, “the Activities”). I understand that participation in the Activities poses inherent and other risks of INJURY and DEATH. The risks associated with the Activities include, but are not limited to, falling; landing on or striking padded or unpadded surfaces; being injured by falling objects or participants; being injured by the actions or inactions of other participants, including but not limited to other participants’ failure to belay properly; movement of climbing holds; equipment failures of any kind; naturally occurring hazards and dangers of all kinds; steep and uneven terrain and trail conditions including snow (surface and subsurface conditions), ice, rocks, dirt, mud, sand, vegetation, and cliffs; hazards associated with changes in weather, temperature, and lighting conditions; and other rugged terrain conditions. The risks also include hazards and dangers associated with the use of manmade structures, vehicles, materials, and equipment, including misuse, defect, failure, or inadequacy of equipment. Other risks include those associated with the use of facilities, including indoor climbing facilities; ropes course facilities; ski resorts including chairlifts, surface lifts, and other conveyances; and participating in instruction and/or special events (collectively, “use of the facilities”). Despite these risks and all other risks, and TO THE FULLEST EXTENT ALLOWED BY LAW, I ACKNOWLEDGE AND AGREE TO EXPRESSLY ASSUME ALL RISKS OF INJURY OR DEATH that might be associated with or arise out of my participation in the Activities or use of the facilities.

In consideration for being permitted to participate in the Activities and engage in use of the facilities, I AGREE TO RELEASE FROM ANY LEGAL LIABILITY AND AGREE NEVER TO SUE Pivot Adventure Company, LLC and all of its successors, heirs, assigns, directors, officers, partners, investors, shareholders, members, agents, employees, owners, volunteers, facility landowners, parent and subsidiary companies, and affiliated companies (collectively herein, “Pivot”) for injury or death resulting from my participation in the Activities or use of the facilities, regardless of the cause, including the alleged NEGLIGENCE of Pivot. I further AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS Pivot for any claims, lawsuits, damages, attorney fees, costs or judgments arising out of my participation in the Activities or use of the facilities.

I UNDERSTAND THIS IS A RELEASE OF LIABILITY that will apply whenever I or my child participate in the Activities or engage in use of the facilities with or associated with Pivot. I understand that this RELEASE OF LIABILITY will prevent me, my child, and our representatives and heirs from filing suit or making any claim for damages in the event of injury or death from my or my child’s participation in the Activities or use of the facilities. Additionally, in the event I file or my child or any legal representative files a claim or a lawsuit arising out of my or my child’s participation in the Activities or the use of the facilities, I AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS Pivot for any damages, attorney’s fees, or costs arising out of such a claim or a lawsuit. With a full understanding of this agreement, I enter into it freely and voluntarily and agree that it is binding upon me, my child, our heirs, assigns and legal representatives.

I UNDERSTAND THAT PARTICIPANTS IN PIVOT ADVENTURE ACTIVITIES MUST HAVE MEDICAL INSURANCE. I confirm that I and/or my child is covered by medical insurance and that if that status changes I will notify Pivot Adventure Co immediately and cease and/or have my child cease participating in Activities until coverage is restored. I understand that I alone am responsible to decide whether I and/or my child should engage in the Activities. I confirm that the participant is physically and mentally capable of participating in the Activities, and I understand that if my or my child’s mental or physical condition changes after the execution of this agreement such that I, he or she is not capable of participating in the Activities, I am responsible to cease and/or have my child cease participating.

I acknowledge that Pivot’s representatives and/or other participants or spectators may photograph or videotape the Activities and facilities, including my or my child’s participation therein. I agree that Pivot may use these recordings in any way, including but not limited to for marketing purposes and as evidence, without compensation or restriction. I understand and agree that this agreement is severable and that if any clause is found to be invalid, the balance of the contract will remain in effect and will be valid and enforceable.

THIS IS A RELEASE OF LIABILITY – DO NOT SIGN UNLESS YOU AGREE TO BE BOUND BY ITS TERMS


Date: May 28, 2020

Pivot Adventure Co. Consumer Agreement

Welcome, you and your family are about to embark on an 8-week adventure course designed to help students level up and to build resiliency needed to overcome life’s challenges. This agreement is to clarify the student and the family responsibilities, logistics and operational aspects of the course

Course Experience 
Pivot Adventure has licensed recreation therapists, social workers and outdoor experts on the team who help develop the curriculum and set goals for activities and discussions. Pivot Adventure will provide weekly activities for students (excluding most school holidays). At each activity students will work on adventure skills such as hiking, mountain biking, outdoor and indoor rock climbing, snowshoeing, cross-country skiing and downhill skiing. Students will also participate in initiative games and group discussions to help build connections with other students and to help them understand and remember concepts they are learning. Each class will build on topics from the previous class so it is important not to miss one. Groups are made up of school-aged youth 12 and older. Parent webinars will be provided throughout the course. In addition, we offer a family workshop at the end (graduation) where the students will show the parents/guardians an activity we have been mastering. At least one parent/guardian is encouraged to attend the parent webinars and the family workshop.

Our course involves challenging situations, introspection and a critical view of deep change. It is not unusual to experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness and helplessness. Vulnerability is a huge part of what we do. This journey is undoubtedly hard work and is truly a process. It is hard to predict how quickly it will “work” or what specific effects it will have. There are no guarantees of what you will or will not experience. We make no promises of a magic answer to “fix” things. However, with your enrollment our course can lead to reduced stress and anxiety, improved self-esteem, increased self-efficacy, better relationships, solutions to specific problems and significant reductions in feelings of distress.

Gear and Clothing 
Pivot Adventure will provide gear for activities. Students are required to come to the activity in appropriate clothing including athletic shoes and with a small backpack, water bottle and sack lunch. Pivot Adventure will always provide snacks, sunscreen, insect repellant, feminine hygiene products and first aid supplies. For safety reasons, students who arrive in improper clothing or without required personal items may not be allowed to participate in the activity.

Transportation (Pick up and Drop off) 
Transportation is provided from specific high schools. The van will leave 10 minutes after school lets out. It is the student’s responsibility to arrive on time for the outing. It is your responsibility to notify Pivot Adventure prior to departure time if your child will miss an outing. If a student does not check in for an activity by departure time, we will attempt to contact a parent and leave a message. If your child does not attend one of the designated schools, we may arrange to meet you at the mouth of canyons or trail heads to join the group. 

In the event that my child does not check in for an outing, I consent to messages being left at the following phone number. Pivot Adventure will not be responsible for a student that has not checked in for an activity by the time the van is scheduled to depart. If a student requires an authorized adult to pick them up, the adult must be on time. If the authorized person is late, a $50 fee will be charged.

Cost of Services

  • 8 Week Session Fee (1 day per week and 1 family webinar per week) $2,000
  • Late Pick-Up Fee (for students who require authorized pick up) $50
  • Declined Credit Card Fee or $30

Pivot Adventure is an intensive workshop. Students are expected to attend every activity. As small staff ratios are required for individual attention, we are not able to offer make-up classes or refunds if an activity is missed.

Pivot Adventure is an out-of-network course. We encourage families to continue sessions with their current therapist if they have one or to seek one out, however our fees do not cover any additional therapy. We partner with a number of therapists and can provide a release of information agreement to allow us to work with your current therapist and share goals and progress. By partnering with therapists we are able to accelerate the work that has already been started and allow for insurance companies to work directly with the therapist and use medical billing to minimize costs. Therapists conducting therapy sessions outside of activities are therefore partners with Pivot, not employees and are not covered in our fees.

Authorization to Serve and Obtain Emergency Care 
In case of emergency, I authorize Pivot Adventure Co to serve me and/or my minor child and obtain emergency medical care for me and/or my minor child.

Confirmation of Medical Coverage 
I understand that participants in Pivot Adventure Activities must have medical insurance. I confirm that I and/or my child is covered by medical insurance and that if that status changes I will notify Pivot Adventure Co. immediately and cease and/or have my child cease participating in Activities until coverage is restored. I understand that I will also need to email a picture of the insurance card that covers the participant.

Commitment 
Pivot Adventure is a mutual commitment. We commit to welcoming you into a small, focused cohort, and doing everything we can to deliver on the promises of the course. In return, we ask you to commit to spending the time, money and passion it takes to level up. We understand that life can interfere and that plans change, and we’ve tried to create a refund policy that respects you, our students and our mutual commitments. After the enrollment period, we require full payment to secure your spot in the course. No refunds are possible once the course begins. We do appreciate notification of withdrawal as soon as possible so that we can attempt to fill your spot with another student who may be on the waitlist. If you’re unable to participate, we’ll donate half your Enrollment Fee to another students tuition who really needs a leg up.

Withdrawl 
If, in the opinion of our guides, the participant not contributing to the culture of safety and forward motion, we’ll let you know. If you’re still not able to actively participate, we’ll ask you to withdraw from the course. In this situation, no refund is possible, and we’ll donate half your Enrollment Fee to a future student in need.

I have read the Pivot Adventure Consumer agreement and agree to the relationship as outlined.

 

Please select who will be participating...
Minor
Continue
First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Transportation (Pick up and Drop off)*

If authorized pick-up is required, please list authorized people and their relationship to the student.

Pivot Adventure Co. Enrollment Form


Age:
Gender*
Male
Female

Gender Identification if different:

Race/Ethnicity:

Religious Affiliation (optional):

Group Affiliation (For Residential or Sponsored Programs):

School:

Height (ft, in):

Weight (lbs):

Shoe Size:

Adult Shirt Size:
Legal Status:*

Parent/Guardian 1 Information


Parent/Guardian:

Relationship:

Address (if different from Minor):

Phone:

Email:

Employer:

Phone:
Is Parent/Guardian 1 an Emergency Contact?*

Parent/Guardian 2 Information

Relationship:

Address (if different from minor):

Phone:

Email:

Employer:

Phone:
Is Parent/Guardian 2 an Emergency Contact?*

Emergency Contact (other than Parent/Guardian)


Name:

Phone:

Relationship:

Personal medical insurance is required to participate in Pivot Adventure Co. activities. Students must have active health insurance throughout the program and Pivot Adventure Co. must be notified immediately if coverage is lost.


Primary Insurance:

Person Responsible for Payment (if different than client):

Relationship to Client:

Phone:

Insured's Group #:

Insured's Policy #:

Insured's Date of Birth:

Insured's Employer:

Employer Phone:

Secondary Insurance:

Person Responsible for Payment (if different than client):

Relationship to Client:

Phone:

Insured's Group #:

Insured's Policy #:

Insured's Date of Birth:

Insured's Employer:

Employer Phone:

Family Background


Reason for seeking services:
Relationship Status of Parents/Guardians:*

What is the current custody arrangement?

Who is living at Home? (name, age, relationship)

Are there any siblings not living at home? (names and ages)

Comments:

Family History

Check any family medical or mental health history (include parents, siblings, grandparents, aunts, uncles, cousins):
ADHD/ADD
Anxiety
Autism Spectrum
Behavioral addictions
Bipolar
Cancer
Death by suicide
Death from heart condition younger than age 50
Depression
Diabetes
Domestic Violence
Drug or alcohol use/addiction
High blood pressure
High cholesterol
Jail/prison time
Learning disabilities
OCD
ODD
Panic attacks
PTSD
Schizophrenia
Self Harm
Sexual Abuse
Suicide attempts

Please list any other pertinent family medical and mental health history:

Personal History

Check any personal medical or mental health history (student only):
ADHD/ADD
Anxiety
Autism Spectrum
Behavioral addictions
Bipolar
Cancer
Depression
Diabetes
Domestic Violence
Drug or alcohol use/addiction
High blood pressure
High cholesterol
Jail time/prison time/detention center
Learning disabilities
OCD
ODD
Panic attacks
PTSD
Schizophrenia
Self Harm
Sexual Abuse
Suicide attempts
Suicide Ideation

Please list any other pertinent personal medical and mental health history (student only):

Name of Current School:

School District:

Grade:
Currently Attending?*
No
Yes
Current Academics*
Current Behavior*
Current Social*

Comments on current adademic, behvioral and social performance:
Past Academics*
Past Behavior*
Past Social*

Comments on past adademic, behvioral and social performance:
Has your child ever had any testing done through the school?*
No
Yes
Do they have an IEP?*
No
Yes
Do they receive extra services at school?*
No
Yes
Is your child behind on credits?*
No
Yes

Treatment History


Current Treatment Provider:

Previous Treatment:

Behavioral History

Has your child ever been suspended or expelled?*
No
Yes
Has your child had any physical confrontations in the home or with others?*
No
Yes
Has there ever been a DCFS report made involving anyone in the family?*
No
Yes
Has your child ever run away or threatened to run away?*
No
Yes
Does your child show any addictive patterns? (video games, T.V., phone, internet, sex, gambling)*
No
Yes
Has your child ever used drugs/alcohol?*
No
Yes
Does your child have any legal involvement?*
No
Yes
Has your child ever intentionally hurt him/herself?*
No
Yes
Has your child ever attempted or threatened suicide or made statements about wishing they were dead?*
No
Yes
Has your child ever been hospitalized for suicidal thoughts/attempts?*
No
Yes
Does your child experience recurrent thoughts or behaviors that they cannot control?*
No
Yes

Please describe any major events your child has struggled with and when it occurred (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.):

What are your teens strengths (intellectually, artistically, socially, physically, etc.)?

What are your teens limitations (intellectually, artistically, socially, physically, etc.)?

Does your child have any specific triggers that you have identified?

What coping skills does your child currently use?

What are your specific goals for your son/daughter while they are involved in programming with Pivot?

How did you hear about Pivot Adventure Co?


Pivot Adventure Co. Health History

Parent/Guardians are to complete the Health History for the student enrolled and both are to sign the form.


Medicines: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking along with your current dosage:

Please list any medications you carry with you including epipens, inhaler and others.

Allergies

Do you have any allergies?*
No
Yes
What category of allergies do you have?
Medications
Pollins
Food Allergies
Stinging Insects

If yes, please identify specific allergies and describe the severity of the reaction:
Do you carry epinephrine or an epipen?*
No
Yes

General Questions

1. Has a doctor ever denied or restricted your participation in sports for any reason?*
No
Yes

2. Do you have any ongoing medical conditions? If so, please identify below:

Asthma*
No
Yes
Anemia*
No
Yes
Diabetes*
No
Yes
Infections*
No
Yes
Blood Clotting Disorder*
No
Yes

Other
3. Have you ever spent the night in the hospital?*
No
Yes
4. Have you ever had surgery?*
No
Yes

Heart health questions about you

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?*
No
Yes
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*
No
Yes
7. Does your heart ever race or skip beats (irregular beats) during exercise?*
No
Yes
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
High blood pressure
High cholesterol
Kawasaki disease
A heart infection
A heart murmur

Other
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)*
No
Yes
10. Do you get lightheaded or feel more short of breath than expected during exercise?*
No
Yes
11. Have you ever had a seizure?*
No
Yes
12. Do you get more tired or short of breath more quickly than your friends during exercise?*
No
Yes

Heart health questions about your family

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?*
No
Yes
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic rightventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?*
No
Yes
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?*
No
Yes
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?*
No
Yes

Bone and Joint questions

17. Have you ever had an injury to a bone, muscle, ligament, or tendon ?*
No
Yes
18. Have you ever had any broken or fractured bones or dislocated joints?*
No
Yes
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?*
No
Yes
20. Have you ever had a stress fracture?*
No
Yes
21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)*
No
Yes
22. Do you regularly use a brace, orthotics, or other assistive device?*
No
Yes
23. Do you have a bone, muscle, or joint injury that bothers you?*
No
Yes
24. Do any of your joints become painful, swollen, feel warm, or look red?*
No
Yes
25. Do you have any history of juvenile arthritis or connective tissue disease?*
No
Yes

Medical questions

26. Do you cough, wheeze, or have difficulty breathing during or after exercise?*
No
Yes
27. Have you ever used an inhaler or taken asthma medicine?*
No
Yes
28. Is there anyone in your family who has asthma?*
No
Yes
29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?*
No
Yes
30. Do you have groin pain or a painful bulge or hernia in the groin area?*
No
Yes
31. Have you had infectious mononucleosis (mono) within the last month?*
No
Yes
32. Do you have any rashes, pressure sores, or other skin problems?*
No
Yes
33. Have you had a herpes or MRSA skin infection?*
No
Yes
Click to customize question*
No
Yes
34. Have you ever had a head injury or concussion?*
No
Yes
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?*
No
Yes
36. Do you have a history of seizure disorder?*
No
Yes
37. Do you have headaches with exercise?*
No
Yes
38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?*
No
Yes
39. Have you ever been unable to move your arms or legs after being hit or falling?*
No
Yes
40. Have you ever become ill while exercising in the heat?*
No
Yes
41. Do you get frequent muscle cramps when exercising?*
No
Yes
42. Do you or someone in your family have sickle cell trait or disease?*
No
Yes
43. Have you had any problems with your eyes or vision?*
No
Yes
44. Have you had any eye injuries?*
No
Yes
45. Do you wear glasses or contact lenses?*
No
Yes
46. Do you wear protective eyewear, such as goggles or a face shield?*
No
Yes
47. Do you worry about your weight?*
No
Yes
48. Are you trying to or has anyone recommended that you gain or lose weight?*
No
Yes
49. Are you on a special diet or do you avoid certain types of foods?*
No
Yes
50. Have you ever had an eating disorder?*
No
Yes
Do you have any communicable diseases?*
No
Yes

Explain "Yes" to any answers here:

Immunizations

Are your immunizations are up to date?*
No
Yes

I have carefully read, understood this Enrollment Packet and acknowledge that it is accurate to the best of my abilities so that Pivot Adventure Co. can make an accurate and honest assessment whether or not my child/participant is a good fit for this course. I understand that by filling out inaccurate, incomplete or false information I will limit the ability of Pivot Adventure Co. to make an accurate assessment and could increase the emotional or physical risk to my child/participant.

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

I acknowledge that it is the responsibility of the parent/guardian to notify Pivot Adventure Co. if there are any unique individual challenges or problems that are not listed above.

I acknowledge and give consent that a copy of this packet will remain in the student's file and with field staff. I agree that if my student's health changes that it would alter this evaluation. I will notify Pivot Adventure Co. as soon as possible.

The student acknowledges that is it their responsibility to report to the Guides and parent(s)/guardian(s) illness or injury they experience.

First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Transportation (Pick up and Drop off)*

If authorized pick-up is required, please list authorized people and their relationship to the student.

Pivot Adventure Co. Enrollment Form


Age:
Gender*
Male
Female

Gender Identification if different:

Race/Ethnicity:

Religious Affiliation (optional):

Group Affiliation (For Residential or Sponsored Programs):

School:

Height (ft, in):

Weight (lbs):

Shoe Size:

Adult Shirt Size:
Legal Status:*

Parent/Guardian 1 Information


Parent/Guardian:

Relationship:

Address (if different from Minor):

Phone:

Email:

Employer:

Phone:
Is Parent/Guardian 1 an Emergency Contact?*

Parent/Guardian 2 Information

Relationship:

Address (if different from minor):

Phone:

Email:

Employer:

Phone:
Is Parent/Guardian 2 an Emergency Contact?*

Emergency Contact (other than Parent/Guardian)


Name:

Phone:

Relationship:

Personal medical insurance is required to participate in Pivot Adventure Co. activities. Students must have active health insurance throughout the program and Pivot Adventure Co. must be notified immediately if coverage is lost.


Primary Insurance:

Person Responsible for Payment (if different than client):

Relationship to Client:

Phone:

Insured's Group #:

Insured's Policy #:

Insured's Date of Birth:

Insured's Employer:

Employer Phone:

Secondary Insurance:

Person Responsible for Payment (if different than client):

Relationship to Client:

Phone:

Insured's Group #:

Insured's Policy #:

Insured's Date of Birth:

Insured's Employer:

Employer Phone:

Family Background


Reason for seeking services:
Relationship Status of Parents/Guardians:*

What is the current custody arrangement?

Who is living at Home? (name, age, relationship)

Are there any siblings not living at home? (names and ages)

Comments:

Family History

Check any family medical or mental health history (include parents, siblings, grandparents, aunts, uncles, cousins):
ADHD/ADD
Anxiety
Autism Spectrum
Behavioral addictions
Bipolar
Cancer
Death by suicide
Death from heart condition younger than age 50
Depression
Diabetes
Domestic Violence
Drug or alcohol use/addiction
High blood pressure
High cholesterol
Jail/prison time
Learning disabilities
OCD
ODD
Panic attacks
PTSD
Schizophrenia
Self Harm
Sexual Abuse
Suicide attempts

Please list any other pertinent family medical and mental health history:

Personal History

Check any personal medical or mental health history (student only):
ADHD/ADD
Anxiety
Autism Spectrum
Behavioral addictions
Bipolar
Cancer
Depression
Diabetes
Domestic Violence
Drug or alcohol use/addiction
High blood pressure
High cholesterol
Jail time/prison time/detention center
Learning disabilities
OCD
ODD
Panic attacks
PTSD
Schizophrenia
Self Harm
Sexual Abuse
Suicide attempts
Suicide Ideation

Please list any other pertinent personal medical and mental health history (student only):

Name of Current School:

School District:

Grade:
Currently Attending?*
No
Yes
Current Academics*
Current Behavior*
Current Social*

Comments on current adademic, behvioral and social performance:
Past Academics*
Past Behavior*
Past Social*

Comments on past adademic, behvioral and social performance:
Has your child ever had any testing done through the school?*
No
Yes
Do they have an IEP?*
No
Yes
Do they receive extra services at school?*
No
Yes
Is your child behind on credits?*
No
Yes

Treatment History


Current Treatment Provider:

Previous Treatment:

Behavioral History

Has your child ever been suspended or expelled?*
No
Yes
Has your child had any physical confrontations in the home or with others?*
No
Yes
Has there ever been a DCFS report made involving anyone in the family?*
No
Yes
Has your child ever run away or threatened to run away?*
No
Yes
Does your child show any addictive patterns? (video games, T.V., phone, internet, sex, gambling)*
No
Yes
Has your child ever used drugs/alcohol?*
No
Yes
Does your child have any legal involvement?*
No
Yes
Has your child ever intentionally hurt him/herself?*
No
Yes
Has your child ever attempted or threatened suicide or made statements about wishing they were dead?*
No
Yes
Has your child ever been hospitalized for suicidal thoughts/attempts?*
No
Yes
Does your child experience recurrent thoughts or behaviors that they cannot control?*
No
Yes

Please describe any major events your child has struggled with and when it occurred (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.):

What are your teens strengths (intellectually, artistically, socially, physically, etc.)?

What are your teens limitations (intellectually, artistically, socially, physically, etc.)?

Does your child have any specific triggers that you have identified?

What coping skills does your child currently use?

What are your specific goals for your son/daughter while they are involved in programming with Pivot?

How did you hear about Pivot Adventure Co?


Pivot Adventure Co. Health History

Parent/Guardians are to complete the Health History for the student enrolled and both are to sign the form.


Medicines: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking along with your current dosage:

Please list any medications you carry with you including epipens, inhaler and others.

Allergies

Do you have any allergies?*
No
Yes
What category of allergies do you have?
Medications
Pollins
Food Allergies
Stinging Insects

If yes, please identify specific allergies and describe the severity of the reaction:
Do you carry epinephrine or an epipen?*
No
Yes

General Questions

1. Has a doctor ever denied or restricted your participation in sports for any reason?*
No
Yes

2. Do you have any ongoing medical conditions? If so, please identify below:

Asthma*
No
Yes
Anemia*
No
Yes
Diabetes*
No
Yes
Infections*
No
Yes
Blood Clotting Disorder*
No
Yes

Other
3. Have you ever spent the night in the hospital?*
No
Yes
4. Have you ever had surgery?*
No
Yes

Heart health questions about you

5. Have you ever passed out or nearly passed out DURING or AFTER exercise?*
No
Yes
6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?*
No
Yes
7. Does your heart ever race or skip beats (irregular beats) during exercise?*
No
Yes
8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
High blood pressure
High cholesterol
Kawasaki disease
A heart infection
A heart murmur

Other
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)*
No
Yes
10. Do you get lightheaded or feel more short of breath than expected during exercise?*
No
Yes
11. Have you ever had a seizure?*
No
Yes
12. Do you get more tired or short of breath more quickly than your friends during exercise?*
No
Yes

Heart health questions about your family

13. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 (including drowning, unexplained car accident, or sudden infant death syndrome)?*
No
Yes
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic rightventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?*
No
Yes
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?*
No
Yes
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?*
No
Yes

Bone and Joint questions

17. Have you ever had an injury to a bone, muscle, ligament, or tendon ?*
No
Yes
18. Have you ever had any broken or fractured bones or dislocated joints?*
No
Yes
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast, or crutches?*
No
Yes
20. Have you ever had a stress fracture?*
No
Yes
21. Have you ever been told that you have or have you had an x-ray for neck instability or atlantoaxial instability? (Down syndrome or dwarfism)*
No
Yes
22. Do you regularly use a brace, orthotics, or other assistive device?*
No
Yes
23. Do you have a bone, muscle, or joint injury that bothers you?*
No
Yes
24. Do any of your joints become painful, swollen, feel warm, or look red?*
No
Yes
25. Do you have any history of juvenile arthritis or connective tissue disease?*
No
Yes

Medical questions

26. Do you cough, wheeze, or have difficulty breathing during or after exercise?*
No
Yes
27. Have you ever used an inhaler or taken asthma medicine?*
No
Yes
28. Is there anyone in your family who has asthma?*
No
Yes
29. Were you born without or are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?*
No
Yes
30. Do you have groin pain or a painful bulge or hernia in the groin area?*
No
Yes
31. Have you had infectious mononucleosis (mono) within the last month?*
No
Yes
32. Do you have any rashes, pressure sores, or other skin problems?*
No
Yes
33. Have you had a herpes or MRSA skin infection?*
No
Yes
Click to customize question*
No
Yes
34. Have you ever had a head injury or concussion?*
No
Yes
35. Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems?*
No
Yes
36. Do you have a history of seizure disorder?*
No
Yes
37. Do you have headaches with exercise?*
No
Yes
38. Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling?*
No
Yes
39. Have you ever been unable to move your arms or legs after being hit or falling?*
No
Yes
40. Have you ever become ill while exercising in the heat?*
No
Yes
41. Do you get frequent muscle cramps when exercising?*
No
Yes
42. Do you or someone in your family have sickle cell trait or disease?*
No
Yes
43. Have you had any problems with your eyes or vision?*
No
Yes
44. Have you had any eye injuries?*
No
Yes
45. Do you wear glasses or contact lenses?*
No
Yes
46. Do you wear protective eyewear, such as goggles or a face shield?*
No
Yes
47. Do you worry about your weight?*
No
Yes
48. Are you trying to or has anyone recommended that you gain or lose weight?*
No
Yes
49. Are you on a special diet or do you avoid certain types of foods?*
No
Yes
50. Have you ever had an eating disorder?*
No
Yes
Do you have any communicable diseases?*
No
Yes

Explain "Yes" to any answers here:

Immunizations

Are your immunizations are up to date?*
No
Yes

I have carefully read, understood this Enrollment Packet and acknowledge that it is accurate to the best of my abilities so that Pivot Adventure Co. can make an accurate and honest assessment whether or not my child/participant is a good fit for this course. I understand that by filling out inaccurate, incomplete or false information I will limit the ability of Pivot Adventure Co. to make an accurate assessment and could increase the emotional or physical risk to my child/participant.

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct.

I acknowledge that it is the responsibility of the parent/guardian to notify Pivot Adventure Co. if there are any unique individual challenges or problems that are not listed above.

I acknowledge and give consent that a copy of this packet will remain in the student's file and with field staff. I agree that if my student's health changes that it would alter this evaluation. I will notify Pivot Adventure Co. as soon as possible.

The student acknowledges that is it their responsibility to report to the Guides and parent(s)/guardian(s) illness or injury they experience.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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