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Colorado Academy 7/24/23 - Lucky to Ride Participant Waiver

THIS FORM MUST BE READ, COMPLETED IN FULL, SIGNED AND GIVEN TO A LUCKY TO RIDE™ LEADER BEFORE THE PARTICIPANT MAY GO ON THE OUTING.

1.) EXPRESS ASSUMPTION OF RISK, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE AGREEMENTIn consideration for the services of Lucky to Ride™, its outing leaders, officers, agents, and volunteers (collectively referred to herein as “LTR"), I, on behalf of myself and/or as the parent or guardian of the minor child participating in the LTR activity, and our heirs, agree as follows: I understand and am aware that hiking, backpacking, rock climbing, mountain biking, swimming, and related activities including, among others, use of LTR bicycles and other equipment (referred to herein as "Activity"), and transportation to and from such activity, are HAZARDOUS ACTIVITIES involving INHERENT AND OTHER RISKS of injury to any and all parts of the body. I further understand that injuries in the Activity are a COMMON AND ORDINARY OCCURRENCE, and I have made a voluntary choice for myself and/or the minor child listed below to ACCEPT AND ASSUME ALL RISKS OF INJURY OR DEATH that might be associated with or result from this Activity. LTR has put in place preventative measures to reduce the spread of COVID-19; however, LTR cannot guarantee that you or household will not become infected with COVID-19. Further, participating in this Activity could increase your risk and your household’s risk of contracting COVID-19. I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that myself and/or household member may be exposed to or infected by COVID-19 by participating in this Activity and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 during this Activity may result from the actions, omissions, or negligence of myself and others, including, but not limited to, LTR and its employees, volunteers, program participants and their families. To the fullest extent allowed by law, I agree to RELEASE FROM LIABILITY, and to INDEMNIFY AND HOLD HARMLESS LTR from any and all liability on account of, or in any way resulting from, personal injuries, death or property damage, even if caused by NEGLIGENCE, in any way connected with this Activity. I further AGREE NOT TO MAKE A CLAIM OR SUE FOR INJURIES OR DAMAGES RELATING TO THIS ACTIVITY, even if caused by NEGLIGENCE. I understand and agree that this Agreement is intended to be as broad and inclusive as is permitted by law, and if any portion is held invalid, the balance shall continue in full legal force and effect. I agree that no oral representations, statements or inducements apart from this Agreement have been made.


2.) AUTHORIZATION FOR FIRST AID AND MEDICAL TREATMENT I recognize that medical or dental care may be necessary for myself and/or my minor child. I AUTHORIZE LTR AND THE OUTING LEADER(S) TO RENDER FIRST AID OR EMERGENCY CARE, within the scope of the certification of the outing leader(s). In addition, I authorize LTR to call for medical or dental care for myself and/or my minor child if, in the opinion of LTR, medical or dental care is needed. I AGREE TO PAY FOR ALL EXPENSES AND COSTS ASSOCIATED WITH SUCH CARE AND RELATED TRANSPORTATION. In addition, I hereby authorize and consent for any x-ray examination, anesthetic, medical, dental or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and/or emergency staff and/or dentist currently licensed by the state in which treatment is given and the staff of any acute general hospital holding a current license to operate a hospital from the State of Colorado Department of Public Health or the equivalent agency in another state. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the physician in the exercise of his best judgment may deem advisable. It is understood, medical condition allowing, that effort shall be made to consult the undersigned prior to rendering the treatment to the patient, but that any of the above treatment will not be withheld if the undersigned is incapacitated or cannot be reached.


3.) PHOTO & VIDEO RELEASE To accomplish our goals, LTR frequently sends press releases and photographs & video to the media (newspaper, radio, television and the internet) and uses photos/videos in our own publications. It is the right of the individual whether to consent to the use of his/her photograph/videos and/ or name for the above publicity purposes. By signing this form, I hereby authorize LTR to use any photos/videos taken of me during LTR activities.. I HEREBY ACKNOWLEDGE THAT ALL THE INFORMATION I HAVE PROVIDED ON PAGE ONE AND PAGE TWO OF THIS AGREEMENT IS TRUE, CORRECT AND COMPLETE. I AGREE TO UPDATE PAGE 2 OF THIS AGREEMENT AS NECESSARY. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ, UNDERSTOOD AND ACCEPTED EACH OF THE ABOVE PROVISIONS, AND VOLUNTARILY SIGNED THIS AGREEMENT.

May 23, 2024
I Agree


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Third Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Fourth Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Fifth Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Sixth Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Seventh Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Eighth Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Ninth Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Tenth Participant's Name

First Name*

Middle Name

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
Parent or Guardian's Email Address

Email*

Confirm Email*
Participant's Program Specific Information
Program Type
Learn to Earn
Ride
Lucky Bike Club
Other
Participant Type
Youth
Volunteer
Other

Name of organization you are participating through:
Demographic Information*This information will remain anonymous and be used for grants and documentation purposes
Participant's Gender
Participant's Ethnicity
Black or African American
Hispanic or Latino
White
Asian
Hawaiin or Pacific Islander
Native American or Alaskan Native
Mixed/Other
Does participant qualify for free/reduced lunch? *
No
Yes
Have you participated in any Lucky to Ride programs before? *
No
Yes
If so, which programs have you participated in?
Learn to Earn
Ride Program
Bike Club
Maintenance Class
Volunteer
Insurance

Insurance Carrier*

Insurance Policy Number*
Participant's Medical Information

Date of most recent tetanus toxoid booster:

Allergies to drugs, foods, insect bites, etc.:

List all medications for which the participant currently holds a prescription and indicate which ones the participant will be taking during outing(s):

List all medical conditions of which the outing leader should be aware or which may affect the participant's ability to participate in activities (such as asthma, heart disease, diabetes or neuromuscular or skeletal impairment):

Family Physician (Name, Address, Phone):
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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(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*

Middle Name

Last Name*

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

Participant's Height in Inches *

Participant's Age

Participant's Grade in School (if applicable)
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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