o o o o o o o o 6-34 CR 6/18

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28 This frm must be cmpleted by anyne emplyed by the Cuncil. All infrmatin must be cmpleted. The insurance cmpany will nt prcess r apprve if there are blanks. VOLUNTEER Add Driver and/r Check Driving Recrd Request Frm TO: GIRL SCOUT SERVICES Wells Farg Insurance Services USA, Inc 190 River Rad 1st flr Summit, NJ christine.cristadr@wellsfarg.cm COUNCIL NAME: Girl Scuts f Kentucky's Wilderness Rad Cuncil I am Under 21 (Cmplete Name and Date f Birth nly and return nt able t drive) Over 21 (please cntinue) X Add Driver and/r X Check Recrd Name, EXACTLY as it appears n Driver's License Date f Birth License Number License Expiratin Class r Type f License State Years f Driving Experience Name f previus state if less than 5 years in current state: Is driver licensed fr and familiar with type f vehicle t be driven? Yes N If n, when will training be cmpleted? Hw many years f driving experience des driver have in this type f vehicle? What is the driver s experience in the last 5 years? (Persns nt prviding driver's experience infrmatin cannt be apprved t drive cuncil wned, leased, r brrwed vehicles.) This infrmatin is fr the past 5 years nly. Mark Bxes 0 if nne. # fat- Fault Accidents # f Vilatins License Suspended? Explain accidents, vilatins, suspensins. (Use additinal sheet if necessary) Yes N Safe Driving Is A Tp Girl Scut Pririty I warrant the abve infrmatin is true and accurate t the best f my knwledge. I authrize any investigatin f all statements herein and release the abve named Girl Scut Cuncil and its agents frm liability in cnnectin with any such investigatin. I understand that untrue, misleading, r mitted infrmatin may result in dismissal, regardless f the time f discvery by the abve named Girl Scut Cuncil. Signature f Driver Date 6-34 CR 6/18

29 Girl Scuts f Kentucky s Wilderness Rad Cuncil 2277 Executive Drive, Lexingtn, KY HIGH RISK ACTIVITY PERMISSION FORM Event Date This frm is used fr permissin t participate in activities at Cuncil spnsred events. Nt all age grups will be invlved with specific activities because f Safety Activity Check Pints restrictins. Please write in ink, nt pencil! Name Phne Number Address City State Zip Address Trp Number Date f Birth Age Level: BR JR CA SR AM Adult Age (at time f event) ACKNOWLEDGEMENT OF INHERENT RISK, WAIVER AND RELEASE OF LIABILITY. I, the Participant, acknwledge and understand that there are risks inherent in certain activities in Cuncilspnsred events (the Activities r High Risk Activities ). Activities may include, but are nt limited t: hrseback riding, swimming, caneing, sailing, white water rafting, rappelling, rck climbing, prusiking and caving. Activities may als take place n ur Team s Challenge Curse and Climbing Twer. I understand and acknwledge that my participatin in such Activities invlves risks and dangers which include, withut limitatin, the ptential fr serius bdily injury, permanent disability, paralysis, and lss f life; lss f r damage t equipment r prperty; equipment failure; situatins beynd the immediate cntrl f the GSWRC; and ther risks and dangers which may r may nt be readily freseeable r are presently unknwn. I hereby expressly assume all such risks and respnsibility fr any damages, liabilities, lsses, injuries, r expenses that I incur as a result f my participatin in the Activities. I, Participant, fr myself, my heirs, executrs, administratrs, parent/guardian, and any persns r entities cnnected with me, hereby release and discharge GSWRC, its successrs, predecessrs, assigns, affiliates, the respective emplyees, fficers, directrs, r agents f it r them, and all ther individuals r entities wh r that are r might be cnnected with it r them r fund t be jintly r severally liable with it r them ( Released Parties ) frm any and all charges, actins, causes f actin, suits, sums f mney, warranties, cvenants, claims and demands, lsses, expenses r attrney s fees fr any damages r injuries arising in any way ut f my participatin in the Activities, including but nt limited t claims fr liability caused in whle r in part by the negligence f the Released Parties. _ Signature f participant if 18 years ld r ver Date FOR MINOR PARTICIPANTS. As the parent r guardian f the minr participant identified abve, I understand and hereby accept and agree t all f the terms and cnditins described abve n behalf f the minr in cnnectin with the minr s participatin in the Activities. I authrize and grant permissin fr the minr participant identified abve t participate in all Activities. Signature f Parent/Guardian 6-34 CR 6/18 Date Required fr participant under age 18

30 Cnsent fr Treatment High Risk Activity Permissin Frm I hereby authrize Girl Scuts Wilderness Rad Cuncil (GSWRC), its persnnel, and the medical prvider(s) selected by GSWRC t secure and/r administer emergency and/r nn-emergency medical treatment, including but nt limited t emergency care, hspitalizatin, ther rutine care; administering nn-prescriptin and/r prescriptin drugs; prescribing drugs; rdering X-rays, tests r prcedures, r ther treatment; and any ther medical prcedures r related transprtatin arrangements which may be necessary fr my daughter/ward r, if I am a Participant 18 years f age r lder, fr me. I understand that GSWRC will attempt t cntact the parent r guardian f a minr Participant, and/r any ther individual identified as an emergency cntact, as sn as practicable in the event f an emergency. Hwever, I understand that this cnsent is given in advance f any accident, injury, r illness giving rise t the need fr emergency medical treatment. I authrize GSWRC t release any medical recrds necessary fr insurance purpses. I understand and agree that I am slely respnsible fr any csts, fees, payments r expenses assciated with emergency and/r nn-emergency medical treatment. I further understand and agree that GSWRC, its affiliates, and their respective emplyees, fficers, directrs and agents, expressly disclaim respnsibility, and shall have n liability, fr any charges, actins, causes f actin, suits, sums f mney, warranties, cvenants, claims and demands, lsses, expenses r attrney s fees fr any damages r injuries arising in any way ut f emergency r nnemergency medical treatment prvided by GSWRC, its persnnel, and/r any medical prvider selected by GSWRC. Signature f participant if 18 years ld r ver Date _ FOR MINOR PARTICIPANTS: Print Parent/Guardian(s) Name Print Minr Participant s Name Parent/Guardian(s) Signature Date 6-34 CR 6/18

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