Colorado Trek Paper Work Check List

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Giles French
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1 Colorado Trek Paper Work Check List Please make sure you have all your paperwork before sending it in Due June 2 - Paperwork Due June 2 - Full payment of $2400 NAME HATS Release Form Adventure Experience Release Form Dad Daughter/Son AE Camp Registration Form Health Statement Form Dad Daughter/Son Sunscreen Form (child only) Health History Form Dad Daughter/Son Immunization Forms - Daughter/Son only: MUST BE FILLED OUT ON FORMS PROVIDED Noah's Ark Forms Dad Daughter/Son

2 WAIVER, RELEASE, AND INDEMNITY AGREEMENT In consideration of my and/or the minor s participation in any way in any activity ( Activity ) organized or sponsored by HIGH ADVENTURE TREKS FOR DADS & DAUGHTERS, INC., a Texas non-profit corporation ( H*A*T*S ), I, for myself, the minor and each of our respective heirs, executors, legal representatives, successors and assigns hereby execute this WAIVER, RELEASE AND INDEMNITY AGREEMENT (the Agreement ): 1. I understand the nature of the Activity and represent that I and the minor are each qualified, in good health and proper physical and emotional condition to participate in the Activity. If at any time I believe conditions to be unsafe, I and the minor will immediately discontinue further participation in the Activity. 2. I understand and acknowledge that (a) the Activity involves risks and dangers of SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH, as well as property damage or loss ( Risks ). These Risks can arise from, among other things, (a) rafting, canoeing, swimming, bicycling, mountain biking, indoor or outdoor rock climbing, hiking, backpacking, horseback riding, and other outdoor, athletic, or physical activities; (b) NEGLIGENT use or failure of facilities and equipment at such activities; (c) the NEGLIGENCE or lack of adequate training of H*A*T*S personnel, including those who seek to assist with or direct the Activity, rescue operations, or medical or other help either before or after bodily injuries or property damage have occurred. 3. I and the minor expressly assume all of these Risks. My and the minor s participation in the Activity is purely voluntary and we each elect to participate in the Activity in spite of their Risks and the limitations imposed upon our legal rights by this Agreement. 4. The minor and I hereby voluntarily WAIVE, RELEASE, FOREVER DISCHARGE AND COVENANT NOT TO SUE H*A*T*S, its officers, directors, agents, employees, representatives, members, volunteers, successors and assigns, and any other party indemnified and held harmless by H*A*T*S (collectively, the Releases ) from any and all liability, claims, loss, demands, actions or rights of action, costs or expenses (including attorney s fees and expenses) related to, arising directly or indirectly from or attributable in whole or in part to the minor s or my participation in the Activity, INCLUDING but not limited to those arising from, caused by or alleged to arise from or be caused by the NEGLIGENCE OR GROSS NEGLIGENCE OF ANY OF THE RELEASEES (collectively, Claims ). PLEASE INITIAL 5. If, despite this Agreement, I, the minor or anyone else on my or the minor s behalf, makes any Claim against any Release, I will INDEMNIFY, SAVE, AND HOLD HARMLESS the Release from any and all expenses, fees, liability or damage award, or cost of any type (including without limitation attorney s fees and expenses) which they may incur as the result of such Claim, even if the Claim arises from, is caused by or is alleged to arise from or be caused by the NEGLIGENCE OR GROSS NEGLIGENCE OF ANY OF THE RELEASEES...PLEASE INITIAL 6. I understand and agree that H*A*T*S shall have no obligation to pay or furnish insurance to pay for any property damage, medical, dental hospital, or other charges, costs or expenses that I or the minor may incur. I certify that the minor and I have health, accident and liability insurance to cover any bodily injury or property damage the minor or I may cause or suffer while participating in this event, or else I agree to bear the costs of such injury or damage myself. 7. The terms of this Agreement are to be governed by and construed under the laws of the State of Texas, without regard to its rules regarding choice of laws. I agree that exclusive jurisdiction and venue for any dispute arising between H*A*T*S and me or the minor involving his Agreement will be in the District Courts of Dallas County, Texas. Should any term or provision of this Agreement be found to be unenforceable or void, in whole or in part, the balance of the Agreement shall remain in full force and effect. 8. I understand and agree that this Agreement is intended to and shall inure to the benefit and protection of H*A*T*S, its agents, owners, directors, officers, employees, volunteers and any other persons or entities acting in any capacity on its behalf. MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE AGREEMENT, THAT I HAVE READ IT, THAT I UNDERSTAND IT SUBSTANTIALLY AFFECTS MY AND THE MINOR S LEGAL RIGHTS, AND THAT I AGREE TO BE BOUND BY IT. Adult participant: Minor Signature of adult participant: Date Address: Phone EMERGENCY CONTACT INFORMATION Name: Relation: Phone:

3 Dad's Form

4 Daughter or Son Form

5 Daughter or Son

6 Health Statement by Licensed Medical Personnel Dad's From Participant's Name: Birth Date: Trip Date: This program proposed for the above named participant requires participation in activities which are physically challenging, at "high altitude" (9,000 to 13,000+ feet) and in a remote, wilderness environment. These factors can cause surges in blood pressure and heart rates as well as other conditions. Therefore, all participants must be free of medical or physical conditions which might create undue risks to themselves or others. Your response to these questions will aid in the medical screening and care of the participant. I have examined the above participant within 12 months of program date. Date of examination: In my opinion, the above participant IS IS NOT able to participate in the described program. Description of any limitations or restrictions on program activities: The participant is under the care of a physician for the following conditions: Current treatment at the time of this report includes: Prescribes medications being used by participant: Over-the-counter medications used by participant: Any dietary restrictions: Known allergies or drug reactions: Signature of Physician or Nurse Practitioner: Printed Name: Title: Address: Phone: Date:

7 Health Statement by Licensed Medical Personnel Daughter or Son From Participant's Name: Birth Date: Trip Date: This program proposed for the above named participant requires participation in activities which are physically challenging, at "high altitude" (9,000 to 13,000+ feet) and in a remote, wilderness environment. These factors can cause surges in blood pressure and heart rates as well as other conditions. Therefore, all participants must be free of medical or physical conditions which might create undue risks to themselves or others. Your response to these questions will aid in the medical screening and care of the participant. I have examined the above participant within 12 months of program date. Date of examination: In my opinion, the above participant IS IS NOT able to participate in the described program. Description of any limitations or restrictions on program activities: The participant is under the care of a physician for the following conditions: Current treatment at the time of this report includes: Prescribes medications being used by participant: Over-the-counter medications used by participant: Any dietary restrictions: Known allergies or drug reactions: Signature of Physician or Nurse Practitioner: Printed Name: Title: Address: Phone: Date:

8 Daughter or Son

9 AEI Base Camp Health History Form Dad's Form (Please Print Neatly) The purposed program provided by Adventure Experience, Inc. requires participation in physical activities which are, by nature, physically demanding. many of the activities as well as being high altitude will challenge you, both of which can cause surges in blood pressure and heart rates. it is imperative that you are free of any heart related or other diseases. therefore, all participants must be free of medical or physical conditions which might cause undue risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of outdoor activities. As required by the State of Colorado, participants under the age of 18 must submit a statement confirming a physical examination within the last 24 months by a physician or nurse practitioner. Name: Birth Date: Age: Health History: (Circle the appropriate response and describe any yes answers.) Have you had or do you currently have any heart problems, i.e, strokes, heart attacks, and/or heart related diseases? YES NO If YES, Explain: Do you frequently suffer from pains/pressures in your chest? YES NO Do you often feel faint of have spells of sever dizziness? YES NO Has a doctor ever told you that you have high blood pressure? YES NO Are you a smoker? YES NO (NOTE: If you have had any heart related problems you will need to have a release from a physician in order to participate in any camp activities.) Do you have arthritis, joint or back problems that might be aggravated by exercise? YES NO Have you had any operations, serious injuries or illnesses? (dates) YES NO Do you have any disabilities or chronic recurring illness? YES NO Are there any activates to be limited/discouraged by physician's advice: YES NO Are you allergic to any medications, insects or pollen? YES NO Do you have Asthma? YES NO Do you have Epilepsy? YES NO Do you have Diabetes? YES NO Do you have any prescribed meal plan or restrictions? YES NO Do you have any food allergies? YES NO Are you currently sick and/or using a medication not listed above? YES NO Do you carry family medical/hospital insurance? YES NO Carrier: Policy or Group # Suggestions or health related information for AEI Personnel: General Health Statement: REPRESENTATION AND EMERGENCY AUTHORIZATION This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel selected by Adventure Experiences, Inc. or its agents to order x-rays, routine tests and treatments as well as injections and/or surgery for me or my child as named above. Such authorization for emergency treatment shall also include, but no be limited to, changes incurred for the providing of aid and arranging evacuation if Adventure Experience, Inc. or its agents, determine that such evacuation in necessary or desirable. i further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned. I also understand and agree to abide with the restrictions placed on my camp activities. Signature of Participant: Signature of Parent/Guardian (if under 18): Witness: Date: Date: Date:

10 AEI Base Camp Health History Form Daughter or Son's Form (Please Print Neatly) The purposed program provided by Adventure Experience, Inc. requires participation in physical activities which are, by nature, physically demanding. many of the activities as well as being high altitude will challenge you, both of which can cause surges in blood pressure and heart rates. it is imperative that you are free of any heart related or other diseases. therefore, all participants must be free of medical or physical conditions which might cause undue risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of outdoor activities. As required by the State of Colorado, participants under the age of 18 must submit a statement confirming a physical examination within the last 24 months by a physician or nurse practitioner. Name: Birth Date: Age: Health History: (Circle the appropriate response and describe any yes answers.) Have you had or do you currently have any heart problems, i.e, strokes, heart attacks, and/or heart related diseases? YES NO If YES, Explain: Do you frequently suffer from pains/pressures in your chest? YES NO Do you often feel faint of have spells of sever dizziness? YES NO Has a doctor ever told you that you have high blood pressure? YES NO Are you a smoker? YES NO (NOTE: If you have had any heart related problems you will need to have a release from a physician in order to participate in any camp activities.) Do you have arthritis, joint or back problems that might be aggravated by exercise? YES NO Have you had any operations, serious injuries or illnesses? (dates) YES NO Do you have any disabilities or chronic recurring illness? YES NO Are there any activates to be limited/discouraged by physician's advice: YES NO Are you allergic to any medications, insects or pollen? YES NO Do you have Asthma? YES NO Do you have Epilepsy? YES NO Do you have Diabetes? YES NO Do you have any prescribed meal plan or restrictions? YES NO Do you have any food allergies? YES NO Are you currently sick and/or using a medication not listed above? YES NO Do you carry family medical/hospital insurance? YES NO Carrier: Policy or Group # Suggestions or health related information for AEI Personnel: General Health Statement: REPRESENTATION AND EMERGENCY AUTHORIZATION This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the medical personnel selected by Adventure Experiences, Inc. or its agents to order x-rays, routine tests and treatments as well as injections and/or surgery for me or my child as named above. Such authorization for emergency treatment shall also include, but no be limited to, changes incurred for the providing of aid and arranging evacuation if Adventure Experience, Inc. or its agents, determine that such evacuation in necessary or desirable. i further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned. I also understand and agree to abide with the restrictions placed on my camp activities. Signature of Participant: Signature of Parent/Guardian (if under 18): Witness: Date: Date: Date:

11 Daughter or Son

14 Dad's Form

15 Daughter or Son Form

16 (Dad & Child's names) HATS - High Adventure Treks (Saturday you are rafting)

CAMP & ENRICHMENT PROGRAM WAIVER, INDEMNIFICATION, AND MEDICAL TREATMENT AUTHORIZATION FORM

Participant Name: County: CAMP & ENRICHMENT PROGRAM WAIVER, INDEMNIFICATION, AND MEDICAL TREATMENT AUTHORIZATION FORM 1. EXCULPATORY CLAUSE. In consideration for receiving permission for my/my child s