Participant Waiver

Trips for Kids Metro NY – Participant Liability Waiver & Medical Release

THIS FORM MUST BE READ, COMPLETED IN FULL, SIGNED AND GIVEN TO THE TFKMNY RIDE LEADER BEFORE THE PARTICIPANT MAY GO ON THE OUTING. EXPRESS ASSUMPTION OF RISK, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE AGREEMENT In consideration for the services of Trips for Kids Metro New York, its outing leaders, directors, officers, agents, and volunteers (collectively referred to herein as "TFKMNY"), I, on behalf of myself and/or as the parent or guardian of the minor child participating in the TFKMNY activity, and our heirs, agree as follows: I understand and am aware that mountain biking, swimming, hiking, backpacking, river rafting, canoeing,and related activities including, among others, use of TFKMNY’s equipment such as camp stoves, campfires, knives, tents, backpacks, rafts, canoes, and bicycles (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. To the fullest extent allowed by law, I agree to RELEASE FROM LIABILITY, and to INDEMNIFY AND HOLD HARMLESS TFKMNY 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. 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 TFKMNY 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 TFKMNY to call for medical or dental care for myself and/or my minor child if, in the opinion of TFKMNY, 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 New York 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.

I HEREBY ACKNOWLEDGE THAT ALL THE INFORMATION I HAVE PROVIDED in this electronic Document OF THIS AGREEMENT IS TRUE, CORRECT AND COMPLETE. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ, UNDERSTOOD AND ACCEPTED EACH OF THE ABOVE PROVISIONS, AND VOLUNTARILY SIGNED THIS AGREEMENT. *Checking the Box below is the same as signing the document.*

AgreeDisagree

First and Last Name of Participant (18 and older) or Parent/Guardian of Minor Participant *

PARTICIPANT'S INFORMATION

First and Last Name of Participant*

Birth Date*

Date

Height*

If a minor, Parent's/Guardian's Name (of minor participant)*

Phone Number*

Area CodePhone Number

Email*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Group/Agency Name (for Kids MTB Ride Club enter "Ride Club")

Counselor's/ Group Leader's Contact Number (for Kids MTB Ride Club enter "None")

MEDIA & USE OF NAME To accomplish our goals, Trips for Kids Metro New York frequently sends press releases and photographs to the media (newspaper, radio, television and the internet) and uses photos in our own publications. It is the right of the individual whether or not to consent to the use of his/her photograph and/or name for the above publicity purposes. Unless otherwise stated, I hereby authorize Trips for Kids to use any photos taken of me and/or my minor child during Trips for Kids Metro New York’s activities. **

AcceptDecline

PARTICIPANT'S EMERGENCY MEDICAL INFORMATION

This information may be used for more than one outing. You must inform the outing leader if any of this information changes from outing to outing.

Date of most recent tetanus toxoid booster.

Allergies to drugs, foods, insect bites, etc. *If Yes, list in next box*

YesNo

If yes to last question Allergies to drugs, foods, insect bites, please list below*

List all medications for which the participant currently holds a prescription and indicate which ones the participant will be taking during outing(s): *If none, write "none"..*

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): *

Physicians Name *

Physician's Phone *

Physician's Address *

Medical Insurance Company *

Policy Number

List the TWO persons we should call in case of an emergency. We will try to contact them in the order that they are listed below. *Name, Relationship, Day Phone Number, Evening Number*