Home » Health History Form – Over 18

Participant Forms

Please review and submit the following documentation and forms. If any required fields are left blank, your form will not submit and incomplete fields will be highlighted in red. If you have any questions, please contact our Admissions Manager at 970-533-7492. Thank you!

Hidden
Civi Group Name
Admin: This group will be created and used as a default group if nothing is passed in as groupid in the url in the Civi Group ID field - i.e. this is a catchall for when group ID is incorrectly specified in a shortcode or for other purpose Admins may have in mind. If groupID is supplied in the inbound link to this form, it will be automatically placed in the Civi Group ID hidden field and will be used by the post submit hook logic to add the submitted participant to the group specified by groupid in the url and this field will be ignored.
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Civi Group ID
This field is autopopulated if a link to this form has the link parameter ... &groupid=(groupidnumber) present in the link. This kind of link can be generated with a custom shortcode placed on any Wordpress page - example: [civigravity_groupregistration label="Update Your Information" gid="52" groupid="61"]
Please complete the following form fully and accurately.
My role on this program is:*
Participant Information
Name*
First Last
Date of Birth*
Month
Day
Year
Gender Identity*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
Parent / Guardian Information
Emergency Contact for Participant
Emergency Contact: The first person Deer Hill will call in case of an emergency.*
First Last
Relationship to Participant*
Daytime Phone*
Evening Phone*
Cell Phone*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance Information
Insurance Carrier
Policy/Group Number
Prescription Plan Number
Phone
Copy of Insurance Card
Drop files here or
Accepted file types: jpg, gif, pdf, png, docx, psd, Max. file size: 2 MB.
Please upload a picture or scanned copy of the front and back of the participant's insurance card.
Participant Health Information
Height*
In feet and inches (e.g 5' 9")
Weight*
In pounds
Past and Present Medical Health Issues
Does participant currently have, or have a history of, treatment for any of the following conditions? If yes, please explain. (If, during your Welcome Questionnaire you indicated that participant has any mental health issues, asthma, Asperger’s/Autism or related, please complete the additional forms attached or contact our office to have them sent to you).
Past and Present Medical Conditions*
- Asthma
- Respiratory Problems (not Asthma)
- Skin/Acne Issues
- Anemia/Sickle Cell Trait
- Cardiac Problems (high blood pressure, heart, circulatory)
- Bleeding/Blood Disorder
- Diabetes
- Gastrointestinal Problems
- Head Injury/Concussion or Severe Headaches
- Menstrual Problems/Pregnancy
- Urinary/Reproductive Tract
- Knee/Ankle Issues
- Participant Smokes
- Asperger's, Autism or NLD
- Issues of Illness with High Altitude
- Back Problems
- Seizure Disorder/Epilepsy
- Hepatitis
- Strains/Sprains/Fractures/Scoliosis/Other Orthopedic Issues
- Hearing/Vision Impairment
- Chronic or Episodic Illness/Condition
- Learning Disorder
- ADD/ADHD
- Neurological Issues
- None
Please check the conditions that are or have been a part of the participant's medical health history.
Explanation of Medical Health Issues
Asthma Follow Up Questions
You indicated that the applicant has asthma or shortness of breath. Please help us to understand this condition by answering the questions below. In your responses, please indicate the triggers, the reaction and severity of the asthma and what medications and actions applicant takes to manage an attack. Aspects of a Deer Hill Program that could trigger asthma include (for example): high altitude, vigorous exercise, allergens, dust and cold or damp weather.
How long as the applicant had asthma?
Did a physician diagnose it?
- Yes
- No
What triggers an asthma attack?
What are the current symptoms and severity?
How often do these symptoms occur?
- Frequently
- Sometimes
- Occasionally
- Never or Almost Never
When was the applicant's most recent episode or when did the last symptoms occur? What triggered this attack?
Has the applicant ever needed to visit the Emergency Room due to asthma?
- Yes
- No
Does the applicant carry an inhaler?
- Yes
- No
If yes, please bring a spare.
How does asthma affect the applicant's ability to engage in aerobic activity and exercise?
Has the applicant ever been at elevations above 5,000 feet?
- Yes
- No
Did the altitude affect the applicant's asthma?
- Yes
- No
Which, if any, of the following make the applicant's asthma worse?
- Airborne/Seasonal Allergies
- Hot or Cold Temperatures
- Viruses (such as the Common Cold)
- Foods
- Animals/Insects
- Damp Conditions
- High Altitude
- Exercise
- Dry Conditions
- Dust
- Other
- None
Please Explain.
Dietary Preferences
Please select all that apply*
- Vegetarian
- Pescatarian
- Gluten Free
- Dairy Free
- None of the above
- Other
Please describe 'other' Dietary Preferences
Allergies
This includes those to foods (including nuts), medications, insect bites or stings, animals, plants, dust, pollen or other. Please keep in mind that a food preference is not an allergy.
Allergen 1
Reaction (including Any Triggers)
Treatment Required (If Any)
Allergen 2
Reaction (Including Any Triggers)
Treatment Required (If Any)
Allergen 3
Reaction (Including Any Triggers)
Treatment Required (If Any)
Are any of the participant's allergies severe or life threatening?*
- Yes
- No
*Note: Any participant with a known anaphylactic reaction must bring TWO personal Epi Pens.
What is the nature of the applicant's severe allergy?
- Nuts
- Other Food (not nuts)
- insect Bites or Stings
- Medication
- Other
Please describe the applicant's allergens referred to above. Be specific.
What is the applicant's reaction to this allergen?
What medication does the applicant need to manage her/his allergy?
*Note: Be sure to send extra medication.
Does the applicant need an epi pen for this allergy?
- Yes
- No
*Note: If yes, the applicant must bring two.
Has the applicant ever been to the Emergency Room for this allergy?
- Yes
- No
Please list the nuts to which the applicant is allergic.
Can there be nuts on this trip?
- Yes
- No
If another person eats nuts near the applicant, is s/he likely to have a reaction?
- Yes
- No
Does the applicant manage this well on her/his own?
- Yes
- No
Please include any other details we should know.
*Note: Be sure to send extra medication.
Mental Health
Deer Hill strives to give all of our participants the best support possible while on a program with us. In order to do this, we aim to gather the most current and applicable information prior to the start of the program. If the participant is currently seeking therapeutic treatment, please indicate as such below. This information helps us to manage mental health concerns in remote wilderness and rural village environments.
Therapeutic Treatment*
- Yes
- No
Is the participant currently in therapy, counseling or treatment for any reason? If yes, please contact our Admissions Manager for either a copy of our Mental Health Form or to schedule a private conversation to explain any additional support the participant may need/want during the program.
Swimming Ability
*Note: Please let us know if you have any specific concerns about participant’s participation in swimming or water based activities, and/or if participant has a fear of the water. Some DHE programs require a higher competency level than others. For poor or non-swimmers, please contact the Admissions Office to discuss appropriate program placement for your child.
Participant’s ability to swim in deep water (5 feet or more); consider participant’s comfort level and physical condition.*
Limitations/Accommodations
Considering the nature of DHE activities, does participant have any condition/s or limitation/s (physical, mental, emotional), described in this form, supplemental forms, on the application, during the Welcome Questionnaire or otherwise, which may necessitate care, affect participant’s well-being, the well-being of others, or affect participant’s ability to engage in program activities? If so, please describe below. Include any adaptations or modifications you consider appropriate.
Description of Limitations/Accommodations
Medications
*Note: Use of prescription and non-prescription drugs is a matter that DHE takes very seriously. We require all students to deliver their medications (prescription, over the counter, herbal) to DHE staff at the beginning of the trip. Certain medications may be left in the participant’s possession per our discretion, such as acne medication or asthma inhalers, and other medications may be held by our staff. In either case, participants must understand how to responsibly use and administer their medications, per their physician’s instructions.
Medication 1
Symptom/Condition
Dosage
Current Side Effects/Restrictions
Date Started
Month
Day
Year
Medication 2
Sympton/Condition
Dosage
Current Side Effects/Restrictions
Date Started
Month
Day
Year
Medication 3
Symptom/Condition
Dosage
Current Side Effects/Restrictions
Date Started
Month
Day
Year
Other Health Information
Is there any other health information DHE should have?
Permission to Treat
Please read and sign below.
I, participant and parent of a minor participant, agree as follows: I authorize DHE staff, representatives and/or other medical personnel to obtain or provide medical care for the participant, to transport the participant to a medical facility and to provide treatment (including, but not limited to hospitalization, medications, anesthesia, surgery) they consider necessary for the participant’s health.*
- I agree to the statements herein.
I agree to pay all costs associated with this care and transportation, including but not limited to medical evacuation, travel, compensation and expenses for staff accompanying participant, medicine and treatment. I agree to the release (to or by DHE representatives) of any records necessary for treatment, referral or otherwise. I certify that the information provided above, and in any supplemental DHE medical forms (those completed forms are incorporated by this reference) is true, complete and accurate. Other than any limitation/s described in this form or supplemental forms, I agree participant can participate in all DHE activities. I understand the nature of DHE activities, and acknowledge that I can contact DHE should I have any questions about these activities and the associated physical, mental or emotional demands or other concerns. I will contact DHE if any medical history/condition changes before the start of (or during) the program and understand that all participants share in the responsibility for their own well being and the well-being of others on the expedition. I acknowledge that providing inaccurate medical information or falsifying medical information can create serious risks to participant or others, and/or result in participant’s dismissal from the program. I understand that participant’s final acceptance and participation in the program is contingent upon DHE’s receipt and review of all forms, including this form and all supplemental medical forms. I understand that although DHE will review this information and may allow participation, DHE cannot anticipate or eliminate risks or complications posed by a participant’s mental, physical (including fitness level), or emotional condition. I understand that emergency, medical, drug and/or health issues, response, assessment or treatment are included within the scope of – and expressly subject to the terms of – the DHE Acknowledgment and Assumption of Risks & Release and Indemnity Agreement. The participant and the parent of a minor participant (those under 18 years of age) must sign below.
Participant Signature*
Participant Name*
First Last
Date*
Month
Day
Year
*
- I agree to the statement above.
Photo Statement/Authorization
As adult participant or parent of a minor, I authorize DHE or parties designated by DHE, to take photos or other images, audio or video recordings, and/or written or spoken statements (including quotations from correspondence) of or including the participant and his or her family, without compensation, and use these materials, including for sale, reproduction or display on the internet or via other media, in DHE catalogues or other materials, or for any promotional, educational or other use. These materials are the sole property of DHE.*
As adult participant or parent of a minor, I authorize DHE or parties designated by DHE, to take photos or other images, audio or video recordings, and/or written or spoken statements (including quotations from correspondence) of or including the participant and his or her family, without compensation, and use these materials, including for sale, reproduction or display on the internet or via other media, in DHE catalogues or other materials, or for any promotional, educational or other use. These materials are the sole property of DHE.
- Yes
- No
Signature*
Activities Permission
As adult participant or parent of a minor, I authorize permission for participation in all Deer Hill activities as outlined for this program.*
As adult participant or parent of a minor, I authorize permission for participation in all Deer Hill activities as outlined for this program.
- Yes
- No
Please outline any exclusions of activities:
Signature
Agreement
To submit this form, you must read and sign our Acknowledgment and Assumption of Risk.
View Assumption of Risk (AOR)*
- View AOR
Acknowledgment and Assumption of Risk
Please read this brief message to familiarize yourself with our Risk Management practices. You will need to e-sign below, acknowledging that you have read it, in order to participate in this expedition.
Risk Management Practices at Deer Hill Expeditions (DHE) and the Acknowledgement and Assumption of Risks & Release and Indemnity Agreement (“Agreement”)
DEAR PARTICIPANT AND PARENT/S, When we founded DHE in 1984, with the dream of creating fun and expansive adventures in wilderness and service for young people, we could not have anticipated how complex the world of risk management and liability would become for programs like ours. Before you dive into this realm, and review and sign the Agreement that follows, we want you to know that after 30 years we remain deeply connected to all aspects of our DHE expeditions and committed to honest and open communication with you. DHE’s safety record is excellent. Of the thousands of young people DHE has taken on extended expeditions into the wilderness since 1984, not one has had an injury that resulted in an overnight stay in a hospital or long-term complications. In addition, in 2001 DHE sought accreditation with the Association for Experiential Education (AEE), an international leader in the field of Outdoor Programming and Risk Management. Since then DHE has been re-evaluated and renewed each year. Although no program can guarantee safety, and likewise, accreditation is not a guarantee of safety, DHE AEE accreditation is evidence of the priority DHE places on its programs and on its on-going attention to risk management practices. A few things about the attached Agreement: The “Acknowledgment and Assumption of Risks” section of the Agreement identifies some of the activities and inherent and other risks that participants may or will be exposed to, and possible outcomes. Recreation and adventure activities include inherent risks; indeed, risks which are central to adventure. With inherent risks can come the education, confidence, resourcefulness and independence participants learn as they spend time together and in the backcountry. Other risks, not inherent, also exist. In the Agreement, participants and parents of minor participants acknowledge and assume these risks. The “Release and Indemnity” section of the Agreement releases and indemnifies DHE from certain claims made against it, including those based upon negligence. Deer Hill does not seek this protection with regard to gross negligence or willful or wanton misconduct. DHE seeks this protection because of the litigious climate existing in our society today – circumstances that neither you, nor DHE created. DHE cannot eliminate risk, but does endeavor to manage risks in its programs, as illustrated by a few examples, below: Hiring leaders DHE trains in the same rivers, canyons, and mountains where DHE programs take place. Guiding DHE participants into backcountry areas of the Colorado Plateau, the region where DHE has traveled for over a 30 year period. Using DHE guides and equipment for each activity, rather than relying on subcontracted outfitters whose risk management approach is not overseen by DHE. For our Costa Rica programs, partnering with Exploradores Outdoors (OE), a trusted outfitter, for over 10 years. In addition to OE providing logistical support, DHE leaders combine their skills with those of OE’s local guides to provide the same quality and safe programming that we do here in the American Southwest. Developing, evaluating and updating DHE risk management policies. Teaching participants that in an expedition team, each individual shares in the responsibility for their own well-being and the well-being of others in the group. Ongoing Accreditation and regular review by AEE. Our leaders are trained in wilderness first aid, search and rescue, and emergency management. Participants, for their part, must come to us prepared to listen, to follow instructions, and to take responsibility for their own well-being. We offer this information to you openly and willingly. As always, if you have any questions or concerns about our program or the Acknowledgement and Assumption of Risks & Release Indemnity Agreement, someone at Deer Hill would be happy to speak with you. Sincerely, Doug and Beverly Capelin Founders and Owners
INTRODUCTION
Please read this entire Acknowledgement and Assumption of Risks & Release and Indemnity Agreement (hereafter, “Document”) carefully before signing. This Document informs you about your responsibilities and assumption of risks, and includes a release of liability, indemnification and surrender of certain legal rights. The participant must sign this Document. For participants under 18 years of age (hereafter sometimes ”minor” or ”child”), one or both parent/s or guardian/s (hereafter collectively “‘parent/s”) must also sign. In consideration of the services of Deer Hill, Inc., dba Deer Hill Expeditions, and its owners, officers, employees, agents, representatives, volunteers (including consulting physicians), independent contractors and all other persons or entities associated with it (individually and collectively referred to in this Document as ”DHE”), in allowing participant to participate, (participant and parent/s of a minor participant), acknowledge and agree as follows: ACTIVITIES, RISKS AND ACKNOWLEDGMENT AND ASSUMPTION OF RISKS Participating in DHE educational, instructional, recreation and/or adventure activities includes risks. Activities can take place in Colorado or in other locations in the U.S. or foreign countries and can include, but may not be limited to: hiking, backpacking, rock climbing, mountaineering, route-finding, camping, whitewater rafting, kayaking, canoeing, surfing, swimming, mountain biking, participation in service learning projects, homestays, interactive games and other sporting activities; socializing; use of any equipment, facilities or premise and transportation in vans, planes, boats, buses and/or other vehicles (collectively referred to in this Document as ”activities”). These activities may be organized or led by DHE staff or contractors and be scheduled or unscheduled, mandatory or optional, supervised or unsupervised and include free time, I (and my parent/s, if I am a minor) acknowledge that the inherent and other risks, hazards and dangers (collectively referred to in this Document as “risks”) of these activities can cause injury, damage, death or other loss to participant or others. Parent/s of minors give permission for their child to participate in all DHE activities and agree to discuss the nature of these activities and risks with their child.
The following describes some, but not all of those risks, as applicable to participant’s activities:
Risks present in an outdoor or wilderness environment These risks include travel in high altitude, mountainous or wilderness terrain both on and off trail and on land or water. Participants’ travel may be subject to storms, including lightning, strong winds, rain or snow; fast moving rivers or other water bodies; difficult stream crossings, currents or whitewater; extremely hot or cold weather or cold water; falling rocks; fallen or falling timber; stinging, venomous and/or disease carrying animals or insects; poisonous plants; aggressive wildlife and other natural or man-made hazards. Hazards (both on land and above and below water level) may not be marked or visible and weather can be unpredictable year around. Risks associated with travel outside the U.S. Travel can involve unique risks, such as political unrest, terrorism or warfare, contact with unusual diseases or bacteria, exposure to contaminated food or water, dangerous road or travel conditions, thievery, abduction and other risks. Participants may be subject to laws and legal systems in foreign countries that do not provide the same protections as the U.S. legal system. NOTE: Although DHE considers current geo-political climates in choosing program locations, DHE personnel are not experts in assessing the likelihood of terrorist activity, political unrest, the need for vaccinations or other issues. Parent/s are responsible for conducting their own independent investigation through the U.S. State Department, Centers for Disease Control, World Health Organization or other sources, should they have concerns about program locations. Risks involved in judgment and decision-making. These risks include the risk that the participant or a co-participant, DHE staff member, representative, volunteer or other person may misjudge the participant’s (or others) capabilities, health or physical condition, or misjudge some aspect of instruction, medical treatment, weather, terrain, water level, or, river and/or terrain route location. Personal health and participation risks. The risk that participant’s mental, physical or emotional condition (including any use or abuse of alcohol or prescription or non-prescription drugs), whether disclosed or undisclosed, known or unknown, combined with participation in these activities could result in injury, damage, death or other loss. Although DHE personnel may have reviewed participant’s medical information and allowed participant to participate, DHE cannot anticipate or eliminate risks or complications posed by participant’s mental, physical (including fitness level) or emotional condition. Whitewater rafting, kayaking and canoeing risks. These risks include potential water obstacles or hazards such as rapids, boulders, trees, fences, waterfalls, holes, reversals; the risk of slipping on wet rocks; falling overboard; impacting the lake or river bottom; being swept into a river current or experiencing a boat capsize or collision. Risks associated with any outdoor or athletic activity. These risks include the risk that a participant may overestimate their abilities or fitness; be inattentive; lose control and trip or fall (from a bike or otherwise) and/or collide with, for example, others, the ground, rocks, cactus, trees or encounter other animal/water/terrain/road/trail hazards; misuse, or not understand the functioning of a bike or other equipment; not understand the effects of uneven, rough terrain on the handling of a bike or other equipment; not control his/her speed;; fall over cliffs; fail to negotiate steep or difficult terrain or experience equipment malfunction. Service learning project risks. Participating in service learning projects can include risks associated with activities such as building, digging, lifting, painting, construction and clean-up projects. Projects may include the use of tools and equipment (e.g. drills, saws, axes, shears) that can cause injury resulting from use, misuse or malfunction. Premises risks. Participants engage in activities on DHE premises. Boulders, ruts, slippery walkways, ponds and other water sources, uneven ground or other conditions may exist in and around the property. Risks present in a city, town, or village environment. These risks include getting lost, theft, harassment, traffic, aggressive or disease-carrying domestic or feral animals; and the unpredictable nature of other people with whom participants may come in contact, none of which can be controlled or anticipated by DHE. Risks associated with travel. Travel can be on foot or by vehicle, boat, or other means and can be over rough and unpredictable terrain or via lakes and rivers, in snow, sleet, rain or other adverse weather conditions. Risks connected with geographic location. Activities may take place in remote locations, several hours or up to a day from medical facilities, causing potential delays or difficulties with communication, transportation, evacuation and medical care. Although DHE staff may have wireless communication devices (including cell or SAT phones) while conducting programs both on and off DHE grounds, use of these communication devices in outdoor, mountainous, wilderness and/or any other terrain is unreliable and inconsistent. Equipment risks. The risk that equipment used in an activity may break, fail or malfunction. This includes participant’s personal equipment or DHE equipment (whether purchased borrowed or rented). Participants choosing to bring and use their personal equipment (including any safety gear) assume full responsibility, along with their parent/s, for choosing appropriate equipment and for the fit and condition of their equipment. DHE requires use of helmets or other safety gear for some activities. Safety gear may prevent or lessen injuries in some instances; however, use of this gear is not a guarantee of safety, and injury can occur even with the use of such gear. Cooking and camping risks. Participants can cook over a gas stove or an open fire and are subject to the risk of gas explosion, scalding or other burns and water contamination in natural water sources. Water should be disinfected, filtered or boiled before use. Camp sites may be subject to high winds, falling trees and/or branches, floods, wildlife disturbances, and other hazards. Free time risks. Participants may have free time before, during and after the start of the program, during activities and at various other times. Unsupervised time may include free time and/or brief periods of time, stationary, alone and possibly overnight, in the field (solos). During both supervised and unsupervised activities, all participants share in the responsibility for their own well-being and that of the group. Risks regarding conduct. The potential that the participant, other participants and/or third parties may act carelessly or recklessly. These and other risks may result in participants: Falling partway or falling to the ground; being struck; colliding with objects, people or the bottom of a river or other water body; experiencing bicycle, vehicle or boat capsize, collision or rollover; reacting to high altitudes, weather conditions or increased exertion; becoming lost or disoriented, suffering gastrointestinal complications or allergic reactions or experiencing other problems. These and other circumstances may cause heat or cold related illness or injury (including hypothermia, hyperthermia, cold water immersion, frostbite or heat exhaustion/stroke), dehydration, drowning, high altitude sickness, heart or lung complications, broken bones, paralysis or other permanent disability, mental or emotional trauma, concussions, sunburn or other burns, infections, cuts or wounds or other injury, damage, death or loss. I (participant and parent/s of a minor participant) agree: to review all DHE information received, complete all required forms and abide by the terms of those documents and all rules and other policies; DHE representatives are, and have been available should I have further questions about these activities or the associated risks; to disclose to DHE any mental, physical or emotional condition/s or limitation/s which might affect participant’s ability to participate and agree that participant is fully capable of participating without causing harm to him/herself or others; If participant is borrowing, renting or purchasing new or used equipment from DHE, the equipment comes "AS-IS," and DHE disclaims all warranties, express or implied (including any conditions of merchantability or fitness for a particular purpose) with regard to the equipment. Participant agrees to inspect all equipment before use and notify DHE of any apparent problems or defects with the equipment. The information provided above is not exhaustive, other unknown or unanticipated activities, risks, and outcomes may exist, and DHE cannot assure participant’s safety or eliminate any of these risks; participant (and parent/s of minors) are fully responsible for lost, stolen or damaged equipment; Participant is voluntarily participating with knowledge of the risks. Therefore, participant (and parent/s of minors) assumes and accepts full responsibility for participant, for the inherent and other risks of these activities (both known and unknown) and for any injury, damage, death or other loss suffered by participant (and parent/s of minors), resulting from those risks, and/or resulting from participant’s own negligence or other misconduct. RELEASE AND INDEMNITY AGREEMENT Please read carefully. This Release and Indemnity Agreement contains a surrender of certain legal rights. Certain federal land agencies may restrict service providers from seeking releases of liability for negligence, for injuries or other losses occurring while operating under permit on some federal lands. Therefore, except to the extent a court determines these federal restrictions apply to DHE as a matter of law, I (adult participant, or parent/s for themselves and for and on behalf of their participating minor child) agree as follows: (1) release and agree not to sue DHE, with respect to any and all claims, liabilities, suits or expenses (including attorneys’ fees and costs) (collectively referred to in this Document as ”claim” or ”claim/s”), for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or participation in these activities, including use of any equipment, facilities or premises. I understand I agree here to waive all claim/s I or my child may have against DHE, bind my/my child’s estate and any family member/heir/other party bringing claim/s and agree that neither I, my child, nor anyone acting on my or my child's behalf, will make a claim against DHE as a result of any injury, damage, death or other loss suffered by me or my child; (2) to defend and indemnify(‘indemnify’ meaning protect by reimbursement or payment) DHE with respect to any and all claim/s: (a) brought by or on behalf of me, my child, my spouse or other family member/s, or my/my child’s heir/s or estate for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or participation in these activities, including use of any equipment, facilities and/or premises; and/or (b) brought by a co-participant or any other person for any injury, damage, death or other loss to the extent caused by my/my child’s conduct in the course of participating in these activities, including use of any equipment, facilities or premises. This Release and Indemnity Agreement includes claim/s of or resulting from DHE’s negligence (but not its gross negligence or willful or wanton misconduct) and includes claim/s for personal injury or wrongful death (including claim/s related to emergency, medical, drug and/or health issues, response, assessment or treatment), property damage, loss of consortium, breach of contract or any other claim. OTHER PROVISIONS I (participant and parent/s of a minor participant) agree that Colorado substantive law (without regard to its "conflict of laws" rules) governs this Document, any dispute I/my child have with DHE and all other aspects of my/my child’s relationship with DHE, and agree that any mediation, suit or other proceeding must be filed or entered into only in the Montezuma County, Colorado. I agree to attempt to settle any dispute (that cannot be settled by discussion) through mediation before a mutually acceptable Colorado mediator. I authorize DHE staff, representatives and/or other medical personnel to obtain or provide medical care for me/my child, to transport me/my child to a medical facility and to provide treatment they consider necessary for my/my child’s health. I agree to pay all costs associated with that care and transportation. DHE reserves the right to dismiss any participant whom staff believes, in their sole discretion, presents a safety concern or medical risk, is disruptive, or otherwise conducts him/herself in a manner detrimental to the activities. Use of illegal drugs, tobacco products or alcohol, sexual or other forms of harassment, sexual activity or exclusionary behavior are examples of conduct that DHE considers detrimental to the activities, and that can lead to early dismissal. If participant is dismissed or departs for any reason, participant (and his/her family) are responsible for all costs of early departure whether for medical reasons, dismissal, personal emergencies or otherwise. These costs include, but are not limited to medical evacuation, travel, and compensation and expenses for staff accompanying participant. This Document is intended to be interpreted and enforced to the fullest extent allowed by law. If any portion of this Document is found unlawful or unenforceable, it shall not affect the enforceability of the remaining provisions, and those remaining provisions shall continue in full force and effect. Participant and parent/s of minor participants agree: I have carefully read, understand and voluntarily sign this Document, and acknowledge that it shall be effective and legally binding upon me, my spouse, participating minor child and other children, and participant’s/parent/s other family members, heirs, executors, representatives, subrogors and estate. The participant must sign below. If participant is a minor (those under 18 yrs. of age),one parent, or both parent/s, if available, must also sign below.
Agreement for Assumption of Risk*
- I have read and accept the Assumption of Risk."
Acceptance Signature of Participant*
Use your mouse to sign in the box.
Participant Name*
First Last
Date*
Month
Day
Year
Please Note
If there are incomplete sections in your form, you will be taken to the top of this page. Any incomplete sections will be highlighted in red. When the form is submitted successfully, a confirmation email will be sent to you. If you wish to Save and Continue Later, press the button below. It will re-load this page and provide you with a unique link that will enable you to return to your form from any computer. The link will expire after 30 days. You will also have the option to enter your email address to send the unique link by email. If you have any questions please contact the Deer Hill Office (970)533-7492