OTR Field Trip to Dotsero Crater Waiver, Release, and Medical Emergency Form

Thank you for registering for Field Trip to Dotsero Crater on May 17th. Please complete this form for each person in your party attending this RMAG Field Trip.

PERSONAL INFORMATION:

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Cell Phone Number

Address

Address 2

City

State

Zip Code

MEDICAL INFORMATION:

The following information may be critical to caring for you in case of an injury or sudden illness during the Activity. It will be used only in the event of an emergency, and only if you are unable to communicate this information to those treating you.

Known Dangerous Allergies (please list): (e.g. medicine, food, plant, animal, insect toxin and if you have or need an Epipen):

Medical Conditions: Please describe any medical condition currently requiring special care, medication, or diet that can adversely affect or limit your participation in the activities described in the overview letter. These may include, but not be limited to limited mobility/hearing/sight, fear of heights, dangerous allergies, medical conditions other than those listed below, and pregnancy.

Dietary Preferences: Please list any dietary preferences in the event of a meal and snacks.

Vegetarian	Vegan
Pescetarian	Gluten Free
Other

EMERGENCY CONTACT INFORMATION:

Emergency Contact Name

Emergency Contact Phone Number

PARTICIPATION:

I, hearby state that I wish to participate in the On The Rocks: Field Trip to Dotsero Crater, sponsored by Rocky Mountain Association of Geologists (RMAG). I understand the RMAG is not a professional outdoor organization and offers On The Rocks Field Trips cooperatively. The individuals organizing and leading field trips are providing this service as unpaid volunteers. I recognize, and accept, that any outdoor activity may involve certain dangers, including but not limited to the hazards of falling rocks, temperature, weather, accidents or illness in remote locations, lack of hydration, forces of nature, insects, animals, motor vehicles as driver and as passenger, and the actions of participants and other persons.

Participation Acknowledgement

RELEASED PARTIES:

By executing this release and waiver of liability and indemnity agreement, I voluntarily agree to forever release and discharge the following parties: RMAG directors, employees, officers, agents and trip leaders, trip organizers and any public entity or public employee (whether paid or volunteer) that assists in presenting, organizing and promoting RMAG On The Rocks Field Trips.

Released Parties Initals

RELEASE FROM LIABILITY:

I hereby fully and forever discharge and release the Released Parties from any and all liability, claims, demands, losses, and causes of action whatsoever arising out of any damages, whether in tort or contract or under any statute of any nature, both in law and in equity, including claims for personal injury or death to me or damage to my property arising from the passive or active sole or concurrent negligence or other fault of any of the Released Parties, including but not limited to any claims or losses resulting from any activities in which I may engage during the RMAG On The Rocks Field Trip event, including but not limited to operating any motorized vehicle, as a passenger in any motorized vehicle, or from any other cause that may arise during the event.

Release From Liability Initials

CONTINUATION OF OBLIGATIONS:

I agree and acknowledge that the terms and conditions of the above provisions shall continue in full force and effect indefinitely even upon conclusion of the RMAG On The Rocks Field Trip. I further agree that my heirs, executors, administrators, successors, assigns and personal representatives, or anyone else claiming on my behalf, shall not initiate any lawsuit, cause of action, or claim for damages against any of the Released Parties.

Continuation of Obligations Initials

PHOTO RELEASE:

I grant the Rocky Mountain Association of Geologists (RMAG) my permission to use the photographs from the On The Rocks: Field Trip to Dotsero Crater for any legal use, including but not limited to publicity, copyright purposes, illustration, advertising, and web content.

Furthermore, I understand that no royalty free or other compensation shall become payable to me by reason of such use.

Photo Release Initials

MODIFICATION OF AGREEMENT:

This agreement cannot be modified orally and a waiver of any provision shall not be construed as a modification of any provision herein, as consent to any other provision herein, or as consent to any subsequent waiver or modification.

Modification of Agreement Initials

I have fully informed myself of the contents of this Waiver and Release of Liability by reading before I have signed it.

Type Name (self or child)

By typing my name I acknowledge:

That the medical information provided is accurate to the best of my knowledge and can be release in the event of a medical emergency to emergency personnel
That I have fully informed myself of the contents of this Waiver and Release of Liability by reading before I have signed it on behalf of myself or my child

Date of Signature