Kyle Willis
Risk Management
Plan
Longwood University
2/26/2014
Table of Contents
Purpose of Trip…………………………………………………………….. 1
Demographic Information ………………………………………………….1
Participant Information……………………………………………………..2
Medical History……………………………………………………………..3
Leader Information………………………………………………………….5
Policies and Procedures……………………………………………………...6
Itinerary of Trip…………………………………………….………………..7
Emergency Information……………………………………………………..8
Emergency Action Plan………………………………………………..…...9
Release/Waiver……………………………………………………………..10
Equipment/ Clothing List…………………………………………..………11
Accident Report…………………………………………………...………..12
Purpose of the Trip
The purpose of this three day camping trip is to help at risk youth build character, self esteem,
and self-control. By participating on this camping experience in the wilderness and only relying
on the four staff members, other campers, and themselves, it allows the at risk youth to work on
self discipline, courage, honesty, trust, and respect. The staff members will assist the campers
with any areas of concern as well as teach them wilderness, camping, and survival skills. By the
end of this trip, the at risk campers should have a better sense of what is really important in their
lives by changing their goals and morals into something positive.
Demographic Information
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Participants will be adolescents who are at risk ages 16-18
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There are six campers attending this trip
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The participants are all male
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All are able bodied with emotional or behavioral issues
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Only three out of six participants have been camping before
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Most, if not all have self esteem issues along with bad decision making
Participant Information
Please Print Clearly
Last Name _____________________ First Name _______________________ M.I.____
Date of Birth ________________ Age_____ Sex Male / Female
Address ________________________________ City________________________ State _____
Email ______________________________________ Phone Number (
) _____________
Insurance Provider________________________ Social Security Number________________
Parent/Guardian Signature_____________________________________________________
Emergency Contacts
Name ___________________________________
Relationship to Participant ______________________
Home Phone________________________ Cell Phone_______________________
Name ___________________________________
Relationship to Participant ______________________
Home Phone________________________ Cell Phone_______________________
Primary Insurance
Company Name ________________________________ Phone Number (
) _____________
Name of Insured____________________ Relationship to Participant _____________________
ID Number ____________________ Group Number _________________
Are you currently on any medication? ________ If yes, please list the medication(s)
____________________________________________________________________________
Allergies _____________________________________________________________________
Medical History
Name _____________________________ Age ______ Gender M / F Date ______________
Address _________________________ City ___________________ State_____ Zip _________
Doctor Name ____________________________ Office Phone___________________
Office Address _____________________ City________________ State_____ Zip ___________
Immunizations: Check off any vaccinations you have had and add the year, if known.
Tetanus ________ Varicella (Chicken Pox) shot or illness ________ Pneumonia_______
Influenza (flu shot) _______ Hepatitis A _______ Hepatitis B _______ MMR _______
Meningitis _______ Shingles _______ HPV _______
Medications: Please list all prescriptions and non-prescription medications, vitamins, birth
control pills, inhalers, etc.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies (To medications, food, insects, and animals)
______________________________________________________________________________
______________________________________________________________________________
Current Health Problems: List any current health problems such as high blood pressure, heart
problems, seizures, diabetes, asthma, etc.
______________________________________________________________________________
______________________________________________________________________________
Tobacco Use (Circle one)
Smoke cigarettes: Never / No / Yes (If you never smoked please go to alcohol use question)
Packs/day: _________ # of years: _________ Other tobacco: Pipe Cigar Snuff Chew
Alcohol Use (Circle one)
Do you drink alcohol? No / Yes # of drinks/week: ___________ Beer Wine Liquor
Months/ Years you have been drinking _______________
Drug Use (Circle one)
Do you use marijuana or recreational drugs? No / Yes How long _____________________
Have you ever used needles to inject drugs? No / Yes How long _____________________
Have you had any instances of mental/emotional instability, thoughts or attempts of suicide?
No / Yes Approximate date ______________________
Health Insurance
Insurance name __________________________ Primary card holder _____________________
Policy number __________________ Group number _____________________
Leader Information
Kyle Willis
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Age:26
Male
Bachelors Degree in therapeutic recreation at Longwood University
Masters Degree in therapeutic recreation at Temple University
NCTRC certified specialized in wilderness therapy and outdoor education
Certified in CPR, first aid, and AED
Head supervisor of the trip
Alex Pecararo
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Age 22
Male
Bachelors Degree in recreation with a concentration in therapeutic recreation at Radford
University
NCTRC certified specialized in wilderness therapy
Certified in CPR, first aid, and AED
Assistant supervisor of the camping trip
Has a great deal of experience in the outdoors
Neil Wellons
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Age 24
Male
Bachelors Degree in therapeutic recreation at BYU
NCTRC certified specialized in outdoor education
Certified in CPR, first aid, and AED
Has a lot of experience with at risk youth
Amera Ghanem
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Age 27
Female
Bachelors Degree in therapeutic recreation at Longwood University
NCTRC certified specialized in outdoor recreation
Certified in CPR, first aid, and AED
Has a great deal of experience with emotional and behavioral problems
Policy and Procedures
This document will be read, discussed, and signed by the campers parent/guardian prior to
the trip.
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All staff members must attend a week long wilderness therapy training prior to the trip.
1. After the training, all leaders will be certified in CPR, AED, and first aid
2. Leaders will learn skills that they will be teaching the participants
3. Leaders will gain a better understanding of outdoor education
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All staff will be randomly drug tested and must pass a back ground check prior to being
hired
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All participants are required to drink at least a gallon of water a day to ensure hydration
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All participants will abide by a buddy system
1. Campers must always stay with their buddy unless in group activities
2. If a camper cannot account for their buddy, they must notify a staff
member immediately
3. Campers are required to attempt to form a relationship with their buddy
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All participants will abide by a curfew
1. All campers will be in their tents by 10:00 pm.
2. Every night at 9:45 every camper’s shoes and lanterns will be collected to
ensure they stay at the camp site.
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Any participant that damages property will be responsible for any costs or replacements
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Prior to departure, all participants will be searched
1. Any tobacco, drugs, alcohol, or weapons found during search will be
confiscated and reported to the police.
I have read and understood the policy and procedures for this camping trip.
Participant signature ________________________________________________
Parent/Guardian Signature____________________________________________
Itinerary
Day 1: Friday July, 15, 2014
7:00 a.m. - Arrive at Magnolia Wilderness Program and check in with the leaders
7:15 a.m. - All campers are searched by the leaders of the trip
8:15 a.m. - Campers will get their equipment packed and will be assigned their buddies
9:15 a.m. - Head to Yellowstone National Park (45 minute drive)
10:00 a.m. - Arrive at campsite and begin unloading
10:30 a.m. - Set up their campsite with the proper equipment
11:00 a.m. - Campers and leaders will help make and eat breakfast
12:15 a.m. - 10 mile hike
2:00 p.m. - The group will stop on the trail for lunch
4:00 p.m. - Return to the campsite for reflection and ice breaking activities
4:45 p.m. - Fishing at a nearby lake at Yellowstone
6:45 p.m. - Gather firewood for camp fire
7:30 p.m. - Dinner
8:30 p.m. Reflection and ice breaker activities over the camp fire
10:00 p.m. – Bed time
Day 2: Saturday July 16, 2014
8:00 a.m. - Wakeup call
8:30 a.m. - Breakfast
9:00 a.m. - Ropes course activites
12: 00 p.m. - Reflection
1:00 p.m. - Lunch
2:30 p.m. - Explore Yellowstone; Old Faithful
4:30 p.m. - Swimming in a nearby lake
6:00 p.m. - Dinner
7:30 p.m. - Reflection and smores
10:00 p.m. - Campers go to bed
Day 3: Sunday July 17, 2014
8: 00 a.m. - Wakeup call
8:30 a.m. - Breakfast
10: 00 a.m. - Canoeing
1:00 p.m. - Lunch
2:30 p.m. - Horseback riding
5:30 p.m. - Dinner
6:30 p.m. - Reflection
7:45 p.m. - Pack up campsite
9:00 p.m. - Head back to Magnolia Wilderness Program
9:45 p.m. - Camper pick up
Emergency Information
Destination: Yellowstone National Park in Wyoming
Staff contacts:
Kyle Willis: Cell (540) 630-1333
Alex Pecararo: Cell (804) 398-0650
Neil Wellons: Cell (804) 878-4509
Amera Ghanem: Cell (434) 210-2527
Nearest Hospital:
Old Faithful Hospital
(407) 545-7325
1788 Danbar Way
Cody, WY 37849
Yellowstone National Park
Yellowstone National Park, WY 82190
(866) 256-9046
Magnolia Wilderness Program
(860) 933-5238
CEO of Magnolia Wilderness Program
Mark McEldowney
(860) 933-7651
Yellowstone National Park Law Enforcement
(307) 344-2132
Poison Control
(866) 687-4212
Emergency Protocol Plan
Serious Injury or fatality
1. Kyle Willis will inspect the scene for safety, check for consciousness, and provide the
necessary first aid.
2. While Kyle is tending to the injured camper, Alex Pecararo will call 911 and provide the
directions to the site of the accident as well as direct the ambulance to the injured person.
3. Neil Wellons and Amera Ghanem will secure the safety of the other campers and tend to
other minor injuries.
4. After calling 911, Alex will then notify the emergency contact guardian and secure
approval regarding medical treatment.
5. Kyle will continue providing care to the injured person until the ambulance or police
arrive, with Neil and Amera close by for assistance.
6. Kyle Willis will then fill out an accident report
Lost Camper
1. All leaders will check in with the lost camper’s buddy to gain more information.
2. All leaders, in accompany of the campers will search all the sights within the park such as
tents, shelters, bathrooms, etc.
3. Kyle Willis and Alex Pecararo will notify the camp property manager and ask for some
assistance as they organize a thorough search of the immediate surrounding areas.
4. If the camper is still not found reasonably quickly, Neil Wellons will call the law
enforcement at the park to help search for the missing camper.
5. Amera Ghanem will notify the emergency contact persons.
6. Kyle Willis will fill out an incident report.
Unauthorized Person on Camp
1. Kyle Willis will notify the camp property manager and law enforcement.
2. Alex and Neil will gather the campers in a shelter (tent or bathroom) and take a head
count.
3. If intruder has been sighted, Amera will call 911
4. Group will remain in the shelter until notified by the property manager or law
enforcement officer to do otherwise.
RELEASE AND WAIVER OF LIABILITY
Date______________________
By participating in the three day camping trip to Yellowstone National Park, I understand the
nature of this activity and know that I am qualified and in proper physical condition to participate
in such activity. I acknowledge that if I believe event conditions are unsafe, I will immediately
withdraw from the activity and alert a staff member.
I am aware and understand that participating in activities with Magnolia Wilderness Program,
which include camping, swimming, fishing, hiking, high and low ropes course, horseback riding,
and canoeing, involve a potential risk of physical injury, illness, or possible death. I am also
aware that there may be other risks either not known to me or not easily predictable at this time;
and I fully accept all risks and responsibility for any losses, costs, and damages I bring upon
myself as a result of my participation in the activity.
I agree that I am responsible for my own participation and for my own physical and emotional
well being. I understand that all of the program activities are voluntary but strongly encouraged.
I will not be under the influence of any illegal or chemical substance while participating on this
trip.
I hereby release and agree not to sue Magnolia Wilderness Program, its directors, staff,
volunteers, employees, other participants, and owners of the property on which the activity takes
place, from all liability claims, demands, losses, or damages on my account. I further agree that
if I make a claim against any of the releases, despite this waiver, I will assure and not hold
Magnolia Wilderness Program responsible for any loss, liability, damage, or cost which I may
bring upon myself.
I acknowledge that I have carefully read and understood this liability waiver, as well as the entire
content of this packet. I have had sufficient opportunity to read and understand this document
and I agree to abide by its terms.
Printed name of participant_________________________________________
Signature of participant_________________________________________
Printed name of parent/guardian______________________________________
Signature of parent/guardian___________________________________________
Equipment/Clothing/Supplies
Recommended Supplies
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Sleeping bag
Pillow
Blanket
Flashlight
Sunscreen
Bug repellent
Cooler
Poncho
Towel
Umbrella
Biodegradable Camping
Soap
Toothbrush/toothpaste
Sponge
Deodorant
Water resistant storage
Medications
Backpack/fanny pack
Sunglasses
Water bottle
Snacks
Recommended Clothing
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Hiking shoes or boots
Sneakers
Water shoes
2 pairs of jeans
3 pairs of shorts
4 t-shirts
Bathing suit
2 pairs of sweatpants
Sweatshirt
3 pairs of longer
socks
3 pairs of regular
socks
Underwear
Hat
Rain coat
Provided
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Tents
Cooking equipment
Some food
Lanterns
Tarps
Toilet paper
Axe
Rope
Compass
Fishing gear
First aid kit
Hand wipes
ACCIDENT REPORT
Date of report:
Name of injured person:
Address:
City:
Home Phone:
Cell Phone:
Date of incident:
Time:
Age:
Sex:
State:
Zip:
Number of people in group:
Weather conditions (if applicable) _______________________________
Name 2 witnesses
Name: ____________________________ Phone number: _____________________
Name: ____________________________ Phone number: _____________________
Describe the incident. Include the location of the accident, events leading up to the accident,
what happened, and how many people were involved in the accident.
List the names and phone numbers of those involved in the incident
Did those involved in the incident disregard the rules or orders of the leaders?
please explain.
If so,
Identify who, if anyone was injured and describe the injuries.
Describe what and by whom first aid was given.
Was CPR used?
Was a resuscitator used?
Was law enforcement or EMS squads called?
What time did they arrive?
Was additional medical attention required?
If so, indicate where the individuals were
taken, who provided treatment, and what treatment was given.
SUPERVISOR INFORMATION
Name:
Years of experience:
Phone number:
Number of months/ years employed:
Date:
General comments of employees:
Signature:
Date: