7/29/2019 Trek Forms

1/5

tement of tto ive First Aid Medi

American West Heritage Center4025 S. Hwy 89-91Wellsville, Utah 84339435_24s_6050http://www.awhc.org

Allergies and Medical or physical conditions*:

AMERICAN TTESTHERITAGE CENTERErprienceit!

Statement of Consent to Receive First Aid and Medical Treatment1' I' r , = ,hereby authorize a staffmember to provide emergency first aid tome' in the event of an accident or emergency that renders me unable to communicate whileparticipating in the American West Herit"g. C.nto's Willie Handcart Expterience.2' I hereby authorize a staff member to transport me to a medical facility if I am rnjured duringthe American west Heritage center's wlite Handcart Experience.3' I hereby give my consent to receive medical care, surgery, and/or anesthesia from a physicianor surgeon in the event of an accident or emergency that renders me unable to communicatewhile participating in the American west Heriiage center's Willie Handcart Experience.

Statement of Medical Conditionfo have listed b_e-low *y pr"oribed medications I may take duringthe American west Heritage Center's willie fa/citEipirirrrr. I have also listed all myknown allergies and medical or physical conditions.Prescribed Medications* :

*If there a.re none, please wite NONE.Signature of participant DateSignature ofparent or legal(If participant is under age guardiant8)Parent or Legal Guardian,s prinied Nam"

Date

7/29/2019 Trek Forms

2/5

Rules Agreement X'orm

AMERICANWESTHERITAGE CENTEREtpri:nceit!

have read over all the rules in resards to the AmericanWest Heritage Center's Willie Handcart Experiences and fully understand and agree to abide bythese rules. I understand that my failure to do so may terminate my opportunity to complete thetrek.

Signature of participant Date

Signature of parent or legal guardian Date(If participant is under age 18)Parent or Legal Guardian's Printed Name

American V/est Heritage Center4025 S. Hwy 89-91Wellsville, Utah 84339435-245-60s0htp://www.awhc.org

7/29/2019 Trek Forms

3/5

Insurance an

AnrEnrcax WESTHERITAGf, CENTERAmerican West Heritage Center4025 S. Hwy 89-91

Wellsville, Utah 84339435-245-6As0http://www.awhc.org

Eryer*znccit!Please fill this form out completely. If you have not authorized us to give you first aid andmedical attention YOU MUST FILL IN SECONDARY CONTACT INFORMATION.In case of an emergency contact:

Emergency contact's first and last nartes (PRINT) Phone NumberCell Number

In the event that we cannot contact your Emergency contact person please give us the name andnumber of a secondary person to contact.

Fhone NumberCell Number

Please iist vour health insurance information - this will only be used if transported to a hospital-

HeathAvledical Insurance Company and Address

Policy NumberIMPORTAFIT: A11 sections of this document must be filled out completely and accurately orthe participant may be denied participation in the Willie Handcart Experience.

7/29/2019 Trek Forms

4/5

PARTICIPANT RELEA,SE OF LIABILITYANDASSUMPTION OF RISKAGREEMENT*"-READ BEFORE SIGNIilG*organization Name (Hereafter oalled iheGompany)Participant Name

l.ln consideration of being allowed to participaie in any urqg in the program, related events and activities (hereafier catled theFrogram), I the-undersisjned, acknowledge, appreciais, and agree that:1. The risk of inJury from the actMties involiaed in this program is signifrcant, including the potentialior permanent paralysisanci deaih. These risks include but are not limibd to: Equipment failure and/or malfunctir:n of my orn or otheisequiprnent; my ov/n negligence andior the negligence of others; Athck or encounter with insects, repfiles ard/or animals;Faiigue, chill andlor dizziness which mqy diminish rny/our reaction time and increase tlre risk of accident; Outdoor activiibsalso include but are noi ljrnited to rislc of exposure to elemerrts, excessire heai, hypothermia, irnpact of the body upon thewaiel injeciion of water inio my body oriflces, exposure to anirnals with the isk of lhem kicking, biting, shying away, runningof or othenvise moving in an unanticipated manner causing injury andlor death. I agree to wear aily required safetyequipment and recognize that hilure to do so increases the potential for severe injury or death,2 | KNOWINGLYAND FREELYASSUMEALL SUCH RISKS, boh kncnun and unknown, E\IEN lFARlSlNc FROM THENEGLIGEI{GE OF THE RELEASEES or others, and assume tull responsibility for my participation in tie Program. Iacknonbdge that engaging in firis prograrn requires a degree of skill arrd knowledge I have responsibilities as a participai'rl3. I willingly agree to compty with terms and condltions lor pafiiolpation. I acloowledge that the staf and wlunteers of theReleasees have been available to more fuliy explain to me the nature and phyeical demands of this Program and theinherent risks, herards and dangers as"oc*eO'wtn this activity. lf t observe Lny unusual spnfioant h"zard during mypresence or partic{pation, I will remwe myselifrom partioipafion and bring such to the afteniion of the nearest staFV\Dlunteermember imrnediately.4- | reccgnize that ft may be necessary ior the Releaees to rd.rse orterminate rny paficipaiion if I am judged to beincapable oi meeting the rigon or requirements oi the Program. I accept the Releasees right to take such actions ior thesafety ol myself and/or other participants. l will not engage in any activiiy beyond nry capabilities and will not cause arry thirdparty'to be endangered by any oi my actions during the progntn.5. { certi! that I hane no physical or mental oondition that should prcclude nre lrom participating in the Program and that Iam not participaiing against rnedical advice or treatrnenl ln the event l leel ururell, have any physical complaints or su$ainan injury oi any kind during the course olihe program, l.will notiV the Staff immediaiely.6. By participating in or atending any aciivity in conneciion with this progreun, whether on or ofi the premises, I conserrt to

the use of any phoiographs, pictures, film or videotape taken of me or provided by me tur publicity, prornot on, telwision,uebsites or any other use, and expressly waive any right of privaoy, compensaiion, mpyright o; other ov*rership r[ght.7 . l, far myself and on behaF of my heirs, assigns,'personal represenHi!s and next of ldn, HEREBIf RELEASEINDEMNIFf, AND HOLD HnnMtgsS THE Companv iis ofi-lcers. oficials. agents andior emplovees. other pariicioants.sDongors. advertiggfs. and. ii aoolicab&l. owners and tssors of oremises used to.conduct the event (Reteasees), fiom anyand all claims, demands, losses, and liabilily arising pui of or rehted to any INJURY, DISABILITY gR DEA,TH I raay suffer,or loss or damage to persion or properiy, WHETHER ARISING FRoIJI THE NEGLIGEI'ICE OF THE RELEASEES OROTHERWISE lo the fulleS extent permiltei by larv-I IIAVE READ THIS RELEASE OF LrJlBrLrTy AND ASSUMPTTOH OF BISK AGREEMENT, FULLY UNBERSTAND tTSTERI{IS,.UNDERSTAND THAT I HAVE GIVEN UP SUBSTAT.ITIAL RIGHTS BY SIGNING IT, AND SIGN TT FREELYAND VOLUNTAR}LY WTHOUT AT.IY INDUCEMENT.

Participanf s Signature Age Date PhoneNurnberFOR PARENTS/GUARDTANS OF FARTICTP.ANT OF MINOR AGE TUNDFB AGE',r8 AT TIME OF REGTSJRATIONIThis is to certiffthd l, as parenVguardian with legal responsibilityforihis participar( do consent and agree to hisiherrelease as proMded abcnre ot all the Releasees, and, ior mywlf, my heirs, assigns, and ne* of kin, I release and agrae toindemniiy and hold harmtes ihe Releasees trom any and all liabllity incidenG to nry rninor child's involvsment orparticipation in these programs as prwided abwe, EVEN lF ARISING FROM THE NEGLIGENCE OF THE RELEASEES,b the fullest e$ent pennitai by law.XPanenUGuardian Signature Ernergency Phone Number{s)

7/29/2019 Trek Forms

5/5

9urncnsP-''E--FrlEa oHFi t+,2UtJ;>.+1 x< F-l{ i;EF67. )-1 ,-tj=cnt '!Fl

!0,E:!,of

-U

a'fac0)ol(ocs'=

!gt.lof9Lo-otrqt-CLqt=!o-369,.o=l=L=CLogLT9.oqtU,o

Do=:s.

I3ooo

h:tf(Dfc3oo

c9^l(Da(nooof=fc3o(D

U)E(D-oloo

3oCLo9r3o3!,4,o5'

/^(D--i!_2. Oa0)

o'_ltt->Pd.,(D