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ADIRONDACK TRAIL IMPROVEMENT SOCIETY, INC.

P.O. Box 565, Keene Valley, NY 12943

ATIS Junior Program Health Information, Waiver and Permission to Treat Form

This form must be submitted before the hiker begins the first ATIS trip of the summer.


I hereby give ATIS personnel permission:

1.     To have access to my son / daughter’s medical information included on this form; to provide first aid during the hike/ ATIS sponsored activities; to select medical personnel for the purpose of ordering X-rays, routine tests, or treatment for the listed participant; to make relevant medical information available to medical personnel.

2.     In the event that I cannot be reached in an emergency, I hereby give permission to the health care provider selected by ATIS to hospitalize, secure proper treatment for, and order injections and /or anesthesia and/or surgery for the child named above.

This health information is correct to the best of my knowledge. I believe my child to be physically and emotionally capable of participating in all ATIS activities except as noted. As parent/guardian of the above-named child, I also acknowledge that I am aware of the potential dangers of some activities (steep trails, rough waters, sudden changes in weather, distance from medical personnel and facilities, lack of cell phone or other communication, etc). I understand that the leaders of ATIS activities, while trained in first-aid, are not health professionals and are not qualified to give professional medical treatment. I accept that it is my responsibility to understand the risks of any activity my child signs up for and not to allow participation beyond the child's capabilities. I also waive any and all claims that might otherwise arise against ATIS or its personnel as a result of my child's participation. I understand that the information on this form may assist ATIS personnel, but that its submission does not impose any legal responsibility on ATIS or its personnel.

It is essential that ATIS be made aware of any physical, mental, or emotional condition that would affect the safety of the applicant, other campers, or the staff. I understand that if I fail to make a complete and accurate disclosure, and if my child's undisclosed physical, mental, or emotional condition adversely affects the safety of my child, other campers or the staff at ATIS, my child may be asked to leave the program and I will not receive a refund of participation fees.

Transportation: I understand that parents are responsible to transport their children to and from trailheads. Many families choose to form a carpool at the time of meeting at the hut in the morning. ATIS facilitates by collecting driver volunteer information. Parents are not required to have their child join the carpool. If my child does join the carpool it is “at your own risk”. ATIS carpool parent drivers are volunteers and are not paid by ATIS and are thus not covered by ATIS’s insurance policy.

Acknowledgment: I acknowledge and understand that ATIS trips are not regulated or inspected by the New York State Department of Health. ATIS’s Junior Program is not regulated as a summer day camp because ATIS does not transport participants.

Dismissals: ATIS reserves the right to dismiss any camper if, in our opinion, it is considered in the best interest of the camp community. The following are absolutely prohibited and will result in immediate dismissal:

●    Any illegal activity

●    Possession of firearms

●    The use of and/or possession of any illegal drugs and/or alcohol

●    The use of any tobacco products

●    Unwelcome or exclusionary behavior toward others of any kind (based on identities including, but not limited to race, gender identity, gender expression, sexual orientation, physical ability, physical characteristic, socioeconomic background, nationality, age, religion, or beliefs)

●    Failure to prioritize personal and group safety during participation in ATIS sponsored activities, whether through disregard for stated policies and rules or through negligence

●    Disregard for Leave No Trace principles and/or for the rules and regulations of outdoor places we visit

●    Failure to represent the ATIS and its mission in a positive, professional, and respectful manner

●    Willful disregard for personal and group safety during participation in ATIS-sponsored activities resulting in imminent risk toward self or others

●    Physical or sexual assault; violence or threats of violence toward others

●    Discrimination, harassment, or hostility toward others of any kind (based on identities including, but not limited to race, gender identity, gender expression, sexual orientation, physical ability, physical characteristic, socioeconomic background, nationality, age, religion, or beliefs) ● Bullying

●    Sexual harassment

●    Illegal or unethical activity while participating in ATIS sponsored activities, or outside of ATIS sponsored activities when such misconduct may result in harm to the organization, its members, its staff, or the outdoor places we value

Photos: I hereby give to and grant ATIS the unrestricted right and permission to use and publish any and all photographs and/or videos which its employees, assignees, licensee, or representatives may have taken of my child for any purpose whatsoever, including (but not limited to) illustration, program promotion, publicity, and advertising. I hereby release ATIS from any and all claims and causes of action arising out of use of said photographs and/or videos of my child, including any and all claims for libel.

Assumption of Risk and Liability

In consideration of being allowed to participate in any way in any of the programs, activities and related events of Adirondack Trail Improvement Society (ATIS), I/we the undersigned, for any child/children/person/persons in my care, acknowledge, appreciate and agree that:

1. I acknowledge that hiking, camping, backpacking, rock climbing, paddling, and swimming all entail known and unanticipated risks, including but not limited to steep trails, rough waters, sudden changes in weather, distance from medical personnel and facilities, lack of cell phone or other communication, that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. The risk of injury from the activities involved in this program, activity or event is significant, including the potential for permanent paralysis and death, and while particular skills, equipment and personal discipline may reduce the risk, the risk of serious injury does exist; and

2. I, for any children or persons in my care knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for any children or persons in my care; and

3. I, for any children or persons in my care, willingly agree and comply with the stated and customary terms and conditions for participation. If, however, any children or persons in my care observe any unusual significant hazard during their presence or participation, any children or persons in my care will remove myself/ourselves from participation and bring such to the attention of ATIS immediately; and

4. I, for any children or persons in my care and on behalf of my/our heirs, assigns, personal representatives and next of kin, hereby release , indemnify and hold harmless ATIS, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises or equipment used for the activity, with respect to any and all injury, disability, death, or loss or damage to person or property associated with my presence or participation, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.

I, FOR ANY CHILDREN OR PERSONS IN MY CARE HAVE READ THIS HEALTH INFORMATION, PERMISSION TO TREAT, PHOTO RELEASE, RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I FOR ANY CHILDREN OR PERSONS IN MY CARE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

By entering my electronic signature below, I affirm that I have read and agree to the terms and conditions in this agreement.

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Parent or Guardian's Email Address

Email*

Confirm Email*
Insurance: Each participant is responsible for medical expenses.
Does the insurance company require preauthorization?*
Yes
No

Insurance Company *

Policy # *

Group #

Billing address of Insurance company

Telephone number of Insurance company
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Are there allergies? If yes, please specify. *

Are there any medications that would need to be taken while participating? If yes, please specify. *

Child must be capable of self-medicating since counselors are not permitted to administer medications.

If the hiker requires an EPI-Pen, the counselor must know where the Epi-Pen is or carry the Epi-Pen during the hike.


Please list any additional conditions or concerns we should know about your child’s ability to participate in the program.
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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