Klondike Consent

 

 

 

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LAST NAME:________________FIRST NAME:____________________UNIT #__________k-in

2000 KLONDIKE DERBY PARTICIPATION FORM

GOLDEN GATE STATE PARK, FEBRUARY 25-27, 2000 ARAPAHOE DISTRICT, LONGS PEAK COUNCIL, B.S.A.

NOTE: THIS IS A LEGAL DOCUMENT, SIGNATURES REQUIRED FOR ALL PARTICIPANTS AND BY PARENTS OF PARTICIPANTS UNDER AGE 18. MAKE ONE COPY PER PARTICIPANT AND TURN IN WITH REGISTRATION FORM.

PARTICIPATION AUTHORIZATION, ACKNOWLEDGMENT OF RISK

INFORMED CONSENT, RELEASE OF LIABILITY, AND MEDICAL TREATMENT CONSENT

* I HEREBY CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE NATURE AND SCOPE OF THE ACTIVITY AS PROPOSED ABOVE, AND FURTHER UNDERSTAND THE POTENTIAL RISKS INHERENT IN SUCH TRAVEL AND PARTICIPATION AS DESCRIBED ABOVE INCLUDING BUT NOT LIMITED TO INJURY, ILLNESS OR DEATH FROM EXPOSURE TO COLD, WIND, PHYSICAL EXERTION, COLLISION WITH SLEDS, AND RELATED ACTIVITIES;, AS EXPLAINED IN WRITTEN MATERIALS OR IN MEETINGS WITH ADULT LEADERS. I THEREFORE AGREE TO AND ACCEPT THE RULES AND GUIDELINES FOR PARTICIPATION IN THE ACTIVITY AS DESCRIBED ABOVE. (FOR SCOUT OR VENTURING YOUTH UNDER AGE 18, PARENTAL/GUARDIAN CONSENT REQUIRED AS FOLLOWS): I AUTHORIZE PARTICIPATION BY MY CHILD IN THE ACTIVITY DESCRIBED ABOVE, AND CONSENT TO SUPERVISION OF MY CHILD BY ADULT ADVISORS/LEADERS DURING THIS EVENT. I UNDERSTAND THAT NORMAL SCOUTING SAFETY PROCEDURES AND LEADERSHIP GUIDELINES WILL BE IMPLEMENTED DURING THIS ACTIVITY. I FURTHER RECOGNIZE THAT CERTAIN RISKS MAY BE INHERENT IN THE CONDUCT AND PARTICIPATION IN THIS ACTIVITY WHICH MAY BE BEYOND THE CONTROL OF ADULT LEADERS AND/OR ACTIVITY SPONSORS. I FURTHER CERTIFY THAT I AND/OR MY CHILD IS/ARE MEDICALLY AND PHYSICALLY CAPABLE OF PARTICIPATION IN THIS EVENT AND IS/ARE MEDICALLY CLEARED BY A PHYSICIAN FOR PARTICIPATION IN SUCH ACTIVITIES. IN RECOGNITION OF THE BENEFITS DERIVED BY MYSELF AND/OR MY CHILD, AND IN THE EVENT OF ANY ACCIDENT RESULTING IN INJURY, ILLNESS, DISABILITY, OR DEATH, OR PROPERTY LOSS OR DAMAGE, WHICH MIGHT OCCUR TO MYSELF AND/OR MY CHILD, WHILE TRAVELING TO OR FROM, OR DURING THE CONDUCT OF, THIS EVENT, I AGREE TO INDEMNIFY, AGREE NOT TO SUE, AND AGREE TO HOLD HARMLESS, THE LONGS PEAK COUNCIL BOY SCOUTS OF AMERICA, GOLDEN GATE CANYON STATE PARK, ALPHA PHI OMEGA/VENTURING CREW 492, ACTIVITY SPONSORS, ADVISORS, LEADERS, OTHER TRIP PARTICIPANTS, AND ANY OR ALL AGENTS, EMPLOYEES, REPRESENTATIVES (OR THEIR EXECUTORS OR HEIRS) ACTING ON BEHALF OF SUCH ORGANIZATIONS OR INDIVIDUALS, FROM ALL CLAIMS DAMAGES, LOSSES, INJURIES AND EXPENSES ARISING OUT OF OR RESULTING FROM PARTICIPATION IN THESE ACTIVITIES. I AGREE THE SITE OF ANY LAWSUIT AND THE LAW GOVERNING ANY SUCH LAWSUIT SHALL BE COLORADO AND GOVERNED BY COLORADO LAW. THE TERMS OF THIS AGREEMENT SHALL CONTINUE AND BE IN EFFECT AFTER THE TRIP HAS ENDED. AS LIQUIDATED DAMAGES, I HEREBY AGREE THAT IF THE BOY SCOUTS OF AMERICA OR ANY OF THE INDIVIDUALS OR ORGANIZATIONS NAMED ABOVE IS FORCED TO DEFEND ANY ACTION, LAWSUIT OR LITIGATION INITIATED BY MYSELF, MY EXECUTORS, OR MY HEIRS, ON MY FAMILY'S OR MY BEHALF, MY HEIRS OR EXECUTORS AND I AGREE TO PAY THE BOY SCOUTS OF AMERICA AND ANY OR ALL SUCH ORGANIZATIONS OR INDIVIDUALS NAMED ABOVE, ANY COSTS AND ATTORNEY'S FEES INCURRED IF THEY SUCCESSFULLY DEFEND SUCH ACTION, LAWSUIT, OR LITIGATION.

*MEDICAL TREATMENT CONSENT:

IN THE EVENT OF INJURY OR ILLNESS TO MYSELF AND/OR MY CHILD, I CONSENT TO ADMINISTRATION OF SUCH FIRST AID MEASURES AS MAY BE DETERMINED NECESSARY BY ACTIVITY LEADERS, AND IF DETERMINED NECESSARY, I FURTHER CONSENT TO TRANSPORT BY GROUND OR AIR AMBULANCE AND/OR REFERRAL TO PHYSICIANS AND ADMISSION TO HOSPITALS . I FURTHER CONSENT TO EMERGENT MEDICAL TREATMENT FOR MYSELF AND/OR MY CHILD IF DETERMINED NECESSARY, INCLUDING BUT NOT LIMITED TO, ANESTHESIA, INJECTION, SURGERY, X-RAY, AND MEDICATION, IF I CANNOT BE CONTACTED IMMEDIATELY FOR SUCH CONSENT. I UNDERSTAND THAT REASONABLE EFFORTS WILL BE MADE TO CONTACT ME IN SUCH CASES. PHONE NUMBER WHERE I CAN BE REACHED DURING THIS EVENT IS LISTED BELOW:

MEDICAL CONDITIONS OF PARTICIPANT(S)

PLEASE LIST ANY SPECIAL MEDICAL CONDITIONS WHICH MAY BE IMPORTANT FOR EACH PARTICIPANT

ALLERGIES: FAINTING:

CONVULSIONS SPECIAL MEDICATIONS:

BLEEDING: DIABETES:

ASTHMA: HEART PROBLEMS:

OTHER: SPECIFY:

*PARENTS AND PARTICIPANTS SIGNATURES:

I HAVE READ AND UNDERSTAND THE TEXT OF THE INFORMED CONSENT, WAIVER OF LIABILITY, AND MEDICAL CONSENT ABOVE AND AGREE TO THE TERMS AS STATED WITHOUT RESERVATION. I/We hereby certify that I/We am/are legally empowered to consent to such permission on behalf of the minor child named below.

WITNESS MY HAND AND SEAL THIS __________________DAY OF ____________2000, AT ________________ COLORADO, U.S.A.

x___________________________________________________________________signature of participant

x___________________________________________________________________

signature(s) of parent(s)/guardian(s)

x___________________________________________________________________

signature(s) of parent(s)/guardian(s)

*SIGNATURE OF PARENT(S) OR GUARDIAN(S) (REQUIRED FOR PARTICIPANTS UNDER AGE 18)

PARENTS NAME(S) (PRINT)_____________________________________________________ADDRESS___________________

CITY______________________ZIP________________PHONE_________-_______________

PRINT NAME OF PARTICIPANT_____________________________________________________

TROOP/PACK/POST/CREW UNIT NUMBER_____________________________UNIT SPONSORED BY______________________________________________

UNIT LEADER NAME______________________________________PHONE________________________ADDRESS_____________________________________

ALTERNATE PERSON TO CONTACT IN CASE OF EMERGENCY IF PARENTS CANNOT BE CONTACTED:

_____________________________________________________________PHONE_________________________________

ADDRESS________________________________________________CITY________________ST___ZIP_____________

 

 

 

   

 

 


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Last modified: October 15, 2016.