Name *

First Name

Last Name

Name of parents/guardians:

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of emergency contact: *

First Name

Last Name

Daytime Phone: *

(###)

###

####

Evening Phone: *

(###)

###

####

Is sponsor authorized to approve medical treatment? *

Yes

No

Is participant covered by personal/family medical insurance? *

Yes

No

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association. *

I AGREE

Yes

No

I have read and understand both, the activity information and the participation agreement above. I also understand and agree that, by typing my name below, this form of electronic signature has the same legal force and effect as a manual signature. *

Yes

No