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ROYAL GORGE RAFTING & ZIP LINE TOURS

ROYAL GORGE RAFTING & ROYAL GORGE ZIP LINE TOURS RELEASE OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNIFICATION AGREEMENT. 

***READ CAREFULLY, THIS IS A RELEASE OF LIABILITY & WAIVER OF LEGAL RIGHTS***

 

1. Definitions. The person who is participating in any activity shall be referred to hereinafter as “Participant”. “Undersigned” means only the Participant when the Participant is age 18 or older OR it means both the Participant and the Participant’s parent or legal guardian when the Participant is under the age of 18. “Released Parties” means Royal Gorge Rafting Inc., Royal Gorge Zip Line Tours Inc. Royal Gorge Vacation Rentals; AJET Inc. White Water Bar & Grill Inc. or any of their respective successors in interest, affiliated organizations and companies, insurance carriers, agents, employees, representatives, assignees, officers, directors, members, and shareholders—including Fremont County, CO, the City of Canon City, CO. The “Activity” means taking part in or participating in any activity offered or sponsored by Released parties or their affiliates, including but not limited to: rafting; zip lining; kayaking; hiking; camping; mountain biking; rock climbing; sponsored or hosted events of any nature; renting and using equipment; traveling to and from activity sites; and activities on or use of lodging or facilities of Released Parties.

2. Risks of Activities.

Undersigned agree and understand that taking part in the Activity can be HAZARDOUS AND INVOLVES THE RISK OF PHYSICAL INJURY AND/OR DEATH.  Undersigned acknowledge that the Activity is inherently dangerous and fully realize the dangers of participating in the Activity.  The risks and dangers of the activity include, but are not limited to:  extreme physical demands, exertion and exhaustion, lack of or difficulty in instruction, lack of or difficulty in communication,, equipment malfunction or defect, improper use of equipment, man-made and natural obstacles, lack of medical attention or equipment, negligence or poor decisions of guides or other participants, choice of courses, encountering dangerous wildlife, insects, flora & fauna, changing weather conditions, changing weather and terrain conditions, heat exhaustion and sunburn, driving to and from the Activity site(s), Participant’s poor health or physical condition, known or latent health conditions, including cardiac conditions, mental distress or panic from exposure to any of the above, infection or exposure to viruses or bacteria, and other illnesses, including but not limited to any novel coronavirus, and misunderstanding or underestimation of the Activity and its risks.

 

In addition, risks specific to rafting include, but are not limited to: drowning; heart attack, shock, hypothermia, dehydration, heat exhaustion and sunburn; risks that may arise due to being ejected from a raft and being immersed in cold water; choice of rafting trip or course; misjudgment of difficulty of rapids; negligence of guides or other participants; misjudgment in food storage or preparations; changing water conditions; hidden underwater obstacles, trees or above water obstacles; coming into contact with equipment; slippery terrain and falling, changing and unpredictable currents; swimming in cold water rapids; overturning; improper use of or lack of equipment; jumping or falling off rocks; carrying rafts and other equipment; tripping or falling at the outpost, entrapment of feet or other body parts under rocks or other objects; driving to and from the Activity site(s); and Participant’s poor health or physical condition, mental distress from exposure to any one of the above and latent health conditions which may increase the chances of injury or death.

 

UNDERSIGNED ACKNOWLEDGE AND UNDERSTAND THAT THE DESCRIPTION OF THE RISKS LISTED ABOVE IS NOT COMPLETE AND THAT PARTICIPATING IN THE ACTIVITY MAY BE DANGEROUS AND MAY INCLUDE OTHER RISKS.

3. Release, Indemnification, and Assumption of Risk.  In consideration of the Participant being permitted to participate in the Activity, the Undersigned agree as follows:

(a)  Release.  THE UNDERSIGNED HEREBY IRREVOCABLY AND UNCONDITIONALLY RELEASE, FOREVER DISCHARGE, AND AGREE NOT TO SUE OR BRING ANY OTHER LEGAL ACTION AGAINST THE RELEASED PARTIES with respect to any and all claims and causes of action of any nature, whether currently known or unknown, which Undersigned have or which could be asserted on behalf of Undersigned in connection with Participant’s participation in the Activity, including, but not limited to, claims of negligence, negligence per se, negligent misrepresentation, other tort claims, premises liability, breach of warranty, breach of fiduciary duty, statutory violations, breach of contract and wrongful death.

(b) Assumption of Risk.   Undersigned agree and understand that there are dangers and risks associated with the participation in the Activity and that INJURIES AND/OR DEATH may result from participating in the Activity, including, but not limited to, the acts, omissions, representations, carelessness, and negligence of the Released Parties.  Undersigned acknowledges that participation in the Activity is voluntary.  Undersigned also acknowledge that Participant/s is/are physically and mentally capable of participating in the Activity, yet there is a possibility that Undersigned may underestimate his/her own abilities, and may have physical or mental conditions that may increase chances of injury or death.  By signing this document, the Undersigned recognize that property loss, injury and death are all possible while participating in the Activity.  RECOGNIZING THE RISKS AND DANGERS, UNDERSIGNED UNDERSTAND THE NATURE OF THE ACTIVITY AND VOLUNTARILY CHOOSE TO PARTICIPATE AND ASSUME ALL RISKS AND DANGERS OF PARTICIPATION IN THE ACTIVITY, WHETHER OR NOT KNOWN, DESCRIBED ABOVE, INHERENT, OR OTHERWISE.

(c) Indemnification  Undersigned agree to indemnify, defend and hold harmless the Released Parties from and against any and all liability, costs, property loss, medical bills, loss of income, expenses, attorney’s fees, liens, subrogation rights, and all other damages of any kind or nature whatsoever, and from any suits, claims or demands, including legal fees and expenses whether or not in litigation, arising out of or related to Participant’s participation in the Activity.  Such obligation on the part of Undersigned shall survive the period of Participant’s participation in the Activity.

4.  Equipment Rental. Rented equipment is rented “as is” and with no warranties, express or implied.  Undersigned accept full responsibility for the care of any rented equipment during the rental period.  Undersigned agree to pay for any damage that occurs to the rental regardless of the circumstances under which such damage may occur.  Undersigned agree to pay for any lost rental income for the period the equipment is out of service due to damage for which Undersigned is responsible.  Undersigned agree to pay for any costs incurred in vehicle retrieval for non-mechanical reasons.  Undersigned agree that Released Parties are authorized to charge Undersigned’s credit card for any sums owed.

5. Minor Acknowledgment. By signing this Agreement without a parent or legal guardian’s signature, Participant, under penalty of fraud, represents that he/she is at least 18 years of age. If signing as the parent or guardian of a minor Participant, signing adults represent that they are a legal parent or guardian of the minor.

6. Medical Care.  Undersigned authorize the Released Parties to call for medical care for Participant or to transport Participant to a medical facility or hospital if, in their opinion, medical attention is needed. Undersigned agree to pay all costs associated with such medical care and related medical transportation.

7. Media Release.  Undersigned hereby grants Released Parties the absolute and irrevocable worldwide right, license and permission, without additional cost, to use Participant’s name, likeness, image, voice, and audio footage or film (collectively referred to as “Media”) obtained during Participant’s participation in the Activity.  The Undersigned hereby agrees that all right, title, interest and ownership, including copyright, in and to any tangible work in any Media containing Participant’s image obtained shall be owned exclusively by Released Parties.  Undersigned agrees that as owner of any such Media, Released Parties shall have the exclusive right to exercise all rights granted under copyright protection relative to the Media. Finally, Undersigned releases Released Parties from any and all claims and demands arising out of or in connection with the use of such Media.

8. Miscellaneous.   Undersigned further agree and understand: (a) Participant will not engage in any activities prohibited by any applicable laws, statutes, regulations and ordinances; (b) this Agreement shall be governed by the laws of the State of Colorado, and the exclusive jurisdiction and venue for any claim shall be the District Court of Fremont County, Colorado; (c) THIS AGREEMENT CONSTITUTES THE ENTIRE AGREEMENT BETWEEN THE PARTIES HERETO AND SUPERSEDES ANY AND ALL PRIOR CONTRACTS, ARRANGEMENTS, COMMUNICATIONS, OR REPRESENTATIONS, WHETHER ORAL OR WRITTEN, BETWEEN THE PARTIES RELATING TO THE SUBJECT MATTER HEREOF INCLUDING BUT NOT LIMITED TO ANY PRIOR OR FUTURE REPRESENTATIONS ABOUT THE ACTIVITY ITSELF OR THE SAFETY OF THE ACTIVITY; (d) Undersigned is voluntarily and fairly entering into this Agreement.  Undersigned understand that this Agreement is a contract and shall be binding to the fullest extent permitted by law.  If any part of this Agreement is deemed to be unenforceable, the remaining terms shall be an enforceable contract between the parties.  It is the intent of Undersigned that this agreement shall be binding upon the assignees, subrogors, distributors, heirs, next of kin, executors and personal representatives of the Undersigned.

 

TODAY'S DATE: August 8, 2020

*SELECT ADULT WAIVER FIRST - then, add Minor(s) after completion of ADULT WAIVER. Thank you.
AdultMinor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
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*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
If you are filling this waiver out at our office (Kiosk) - Enter Your Reservation ID#
For our records, please indicate which activity or activities you are participating in. Your selection does not change your waivers intent or viability and is solely used for our records. Thank you.
White Water Rafting
Zip Line Tour
Bike Rental
Admission of Understanding
I the participant(s) clearly understand this waiver is applicable to any and all activities provided by or in conjunction with the Released Parties.
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Notification

MEDICAL CONDITIONS / NOTIFICATION

 (You are not required to provide this information but the consequences of failure to do so are solely your responsibility. Information is confidential.)  Please identify all allergies to food, drugs, insect bites, etc., and the nature of the reaction. Identify any disabilities or conditions that might limit your participation or place you in heightened danger or risk of injury or death from the risks listed in paragraph 2 above.  List conditions, and medication(s) you are currently taking and the reason for its use on the line below

COVID-19 SCREENING: If you are exhibiting the following symptoms leading up to your trip we will NOT allow you to participate in any of our actiities. FEVER - DRY COUGH - SHORTNESS OF BREATH - PERSISTENT PAIN IN YOUR CHEST - LACK OF SMELL OR TASTE


***LEAVE THE SPACE BELOW BLANK IF NOTHING*** 

Otherwise list any concerns we should know about such as: 


Heart conditions, Asthma, Diabetes, Epilepsy, Hemophilia, Thrombosis, Vertigo, Severe allergies, etc. Or any fast acting medications you are bringing on the Activity, i.e. Epinephrine, Heart Nitrates, Albuterol, Glucose, COVID Symptoms: Fever, Dry cough, Shortness of breath, Persistent pain in chest, Lack of smell or taste,

Emergency contact (do not list another trip participant or use 911) 


Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relation: *
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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