Name
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First Name
Last Name
Email
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Phone
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Preferred Contact Method
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How would you like us to contact you first
Address
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Please give us the address you would prefer us to pick you up from?
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Start Date
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When would you like to start joining us on adventures?
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Months
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Are there any months you are out of the valley and would not like to be contacted?
How Much
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How many adventures would you like to join us on a month?
Types
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Are there certain types of adventures you would be more interested in? Select all that apply.
Medical
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Are there any medical/physical limitations you have that we should be aware of? If none, please write "none"
About you?
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Please tell us about you? What you like/dislike. If you enjoy kids or not so much. If you dislike the smell of perfume or other things you know about yourself. We want to be aware of these things so we can better accommodate you and your needs/wants.
How did you hear about our services?
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Please name all the places you have heard about us, so we can thank them.
Main contact/ Emergency Contact
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Please give us the best phone to reach in case of emergency.
(###)
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Would like to sponsor another participant?
Is your income less that $75,000 per year?
Are you currently on Medicaid?
All older adults over the age of 65 are eligible for Medicare. Older adults who have limited income and/or assets may also be eligible for Medicaid.
AC ADVENTURES ASSUMPTION OF RISK, WAIVER AND RELEASE FROM LIABILITY
AC ADVENTURES ASSUMPTION OF RISK, WAIVER AND RELEASE FROM LIABILITY
1. Risks. I understand that all volunteer activities involve various risks, hazards and dangers, including risks of physical injury, disability, or death and risk of loss of use or damage to my personal property. I affirm and acknowledge that I have been sufficiently informed of and understand the inherent hazards and risks associated with any volunteer activity. I also
understand that injury or loss may result from unknown or unexpected risks. These risks may result from the use of equipment, materials, or facilities owned by AC Adventures or others; from the activity itself; from travel; from environmental conditions; from the acts or omissions of others; or from the unavailability of immediate emergency medical care.
2. Assumption of Risks. Knowing the risks, I HEREBY ASSUME ALL RISKS that may arise out of or result from any volunteer activity, including but not limited to the risks described above.
3. Release, Waiver, Indemnity. I HEREBY RELEASE, WAIVE, DISCHARGE, INDEMNIFY, DEFEND, HOLD HARMLESS, AND AGREE NOT TO SUE AC Adventures, its Board of Trustees, officers, instructors, employees, agents, volunteers, and any students acting as leaders, organizers or employees, including as company or agency involved in our activities from, for, or against any liability, claim, demand, suit, or cause of action of any kind, for any property damage, loss or theft, personal injury, death, or disability, or other loss or expense of any kind arising out of or in connection with the Activity, except only for damage, injury, or loss caused by the gross negligence or willful misconduct of AC Adventures
Volunteers.
4. Safety, Policies and Procedures. I understand that AC Adventures takes reasonable efforts to make the Activity safe, but I also recognize that it is impossible for AC Adventures to guarantee my safety, to fully protect me from harm or injury, or to guarantee that the Volunteer Activity will proceed exactly as planned. I understand and agree that safety is a shared responsibility, and as a participant, I have a duty to act with reasonable caution, to be observant of unsafe conditions, to report any unsafe conditions to AC Adventures and to follow all AC Adventures safety and other rules, standards, and instructions for
the Volunteer Activity.
5. Prerequisite Skills/Abilities. I affirm that I have the prerequisite skills, knowledge, and physical ability necessary to properly and safely participate in the Activity and to use the equipment and facilities involved in the activity. If I have any questions or concerns about my abilities to participate in the Activity safely, I will ask AC Adventure staff.
6. Health and Medical Insurance. I certify that I have no medical or health-related problems which would preclude or restrict my participation in this Volunteer Activity. That I have been advised to consult with a doctor if I have any concerns about my ability to participate in this Volunteer Activity. That AC Adventures does not carry any insurance that would cover any injuries or losses I may suffer while participating in this Activity although AC Adventures does carry limited volunteer insurance. I have read and understand the parameters of the AC Adventures volunteer insurance. I acknowledge that I am solely responsible for any and all costs of medical treatment required by me or on my behalf, I agree to pay for such medical treatment, and I assume all risks of such medical treatment. I certify that I have my own health insurance in effect.
7. Consent for Emergency Treatment. In the event I am injured or become ill during the Activity, I authorize AC Adventures to authorize or obtain appropriate medical care and treatment for me, to make medical decisions in my behalf, to place me in the care of a local medical doctor, or to place me in a hospital for any necessary medical treatment, all at my expense. Additionally, I have provided AC Adventures with emergency contact information.
8. Binding Effect. I intend this Release to be fully binding on me and my heirs, successors, assigns, and personal representatives.
9. General Provisions. This Release shall be construed in accordance with the laws of Colorado. Venue for any legal action concerning this Release shall be in Colorado. If any term or provision of this Release is held illegal or unenforceable, all remaining provisions of this Release shall remain in full force and effect. I am not relying on any oral or written representation, statement, or promise other than what is set forth in this Release.
10. Acknowledgment. I have fully read and understand this Release and I agree to be bound by it. I realize it relates to surrendering and releasing valuable legal rights. I sign it knowingly and voluntarily and of my own free will.
I hereby state that all of the information I have provided is true and correct to the best of my knowledge. I agree to all of the terms and conditions listed above and release AC Adventures from any liabilities. By typing my name below, I am signing this agreement electronically.
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Today's Date
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MM
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