Fruita, CO area (Highline Lake, 18 Road, Kokopeli trails, and Colorado National Monument) Saturday, May 30, 2015 to Monday, June 1, 2015

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1 Location: Fruita, CO area (Highline Lake, 18 Road, Kokopeli trails, and Colorado National Monument) Trip Date: Saturday, May 30, 2015 to Monday, June 1, 2015 Trip Departure: Casey Middle School at 8:00 a.m. Trip Return: We will return to Manhattan school by 8:00 p.m. on Monday Equipment/Clothing Information: Winter hat sombrero para invierno Sunglasses Lentes de Sol (gafas) Rain jacket chaqueta o capa para la lluvia Toothbrush & toothpaste (small) cepillo dental y pasta dental (pequeño) Comb/brush peine/cepillo Insulated plastic mug (with lid) taza aislante Gloves or mittens guantes para el invierno Pair of pants (preferably not cotton) pantalones, no de algodón 1 long-sleeved shirts (preferably not cotton) camisa de manga larga, no de algodón si tiene 2 short-sleeved shirt (preferably not cotton) camisa de manga corta, no de algodón si tiene 2 pair of socks (preferably not cotton) calcetines, no de algodón si tiene 3 pair of underwear ropa interior Warm sweatpants (to use as pajama bottoms) pantalones largos de lana para utilizar como pijamas Fleece sweater or light jacket suéter (no de algodón si tiene) Boots or shoes for hiking zapatillas (cómodas, para caminar e ir de excursión) si tiene Medicines or inhalers that you normally use medicinas o inhaladores que usa normalmente Trip Description & Other Important Information: We will have a mandatory pre-trip meeting on Thursday, May 28th at 4:30 p.m. at Manhattan Middle School. Bring as many of items listed on the left as you own to this meeting. On the day of the outing, participants should eat a hearty breakfast before arriving at Casey Middle School at 8:00 a.m. We will then drive about 4.5 hours to Highline Lake state park (exact camping location TBD). Driving directions to Manhattan Middle School are on the next page. Let Ms Powers know if you need a ride to the school for the pre-trip meeting and/or the trip. If you have any questions or do not have any of the listed gear and clothing, please contact David Schneider at or Catherine Powers at Sierra Club will provide: Meals Todos los alimentos Transportation Transportación Any clothes or equipment above that you do not have cualquier ropa o equipo que tu no poseas Camping gear: backpack, tents, sleeping bags, stove, etc. ICO expects: That you respect yourself, others, and the environment. That you not use MP3 players, smartphones, or other entertainment devices during group activities. That you not bring any weapons (including knives) on outings without permission from a leader. That you notify the trip leader as soon as possible if you must cancel. Last- minute cancellations are strongly discouraged. Keep this page PARENT/GUARDIAN SIGNATURES ARE REQUIRED IN FOUR (4) PLACES ON THE FORMS: Publicity permission Assumption of risk Bottom of permission slip Trips for Kids release form

2 Sierra Club s Inner City Outings program in Boulder County receives gear, services, and financial support from the following partners. Driving Directions to Manhattan Middle School Manhattan Middle School is located at 290 Manhattan Drive in South Boulder. Driving Directions to Manhattan Middle School from Lafayette: Take South Boulder road towards Boulder. After you pass Cherryvale Road, start looking for Manhattan Drive on the right. Turn right onto Manhattan Drive and continue a few blocks until you see the school on the right. Driving Direction to Manhattan from North Boulder: Take Broadway south, until you reach Table Mesa Drive. Turn left on Table Mesa Drive and continue until you pass under Foothills Parkway. Once you have passed under Foothills Parkway, look for Manhattan Drive on the left. Turn left onto Manhattan Drive and continue a few blocks until you see the school on the right.

3 Inner City Outings Trip and Participant Information Trip Destination: Fruita, CO area (including Highline Lake, 18 Road, Kokopeli Trails, and Colorado National Monument) Trip Date(s): 5/30/15 to 6/1/15 Departure Time: 8:00 a.m. 5/30 Approximate Return Time: 8:00 p.m. 6/1 Departure Location: Participant Name Casey Middle School Parent/Guardian Name: Address: City, State, Zip: Home Phone: ( ) - Alternate Phone: ( ) - Insurance Company: Policy Number: Family Doctor: Phone Number: ( ) - Trip Participant Information Date of Birth: / / Height Weight List any special health concerns (asthma, contact lenses, etc.) or allergies (to food, drugs, insects, etc.): List all medications being taken, including inhalers. List: purpose of medication, dosage, when to administer, who will administer, and where it will be kept during the outing. Please pack enough for the duration of the trip. Sign Here Publicity Permission Yes No I give permission for my child/guardian s picture and/or words to appear on any medium of communication (for example, radio, television, newspapers, ICO brochure or website) as a means of promoting the Inner City Outings program. Your child will still be able to participate on outings even if you do not agree to this publicity permission. X Signature of parent/guardian Date

4 Acknowledgment of Outing Member Responsibility, Express Assumption of Risk, and Release of Liability and Permission to Participate I understand that during my participation in this Sierra Club Outing, I may be exposed to a variety of hazards and risks, foreseen or unforeseen, which are inherent in each Outing and cannot be eliminated without destroying the unique character of the Outing. These inherent risks include, but are not limited to, the dangers of serious personal injury, property damage, and death ( Injuries and Damages ) from exposure to the hazards of travel and the Sierra Club has not tried to contradict or minimize my understanding of these risks. I know that Injuries and Damages can occur by natural causes or activities of other persons, animals, trip members, trip leaders and assistants or third parties, either as a result of negligence or because of other reasons. I understand that risks of such Injuries and Damages are involved in adventure travel such as Sierra Club Outings and I appreciate that I may have to exercise extra care for my own person and for others around me in the face of such hazards. I further understand that on this Outing there may not be rescue or medical facilities or expertise necessary to deal with the Injuries and Damages to which I may be exposed. In consideration for my acceptance as a participant on this Outing, and the services and amenities to be provided by the Sierra Club in connection with the Outing, I confirm my understanding that: I have read any rules and conditions applicable to the Outing made available to me; and I acknowledge my participation is at the discretion of the leader. The Outing officially begins and ends at the location(s) designated by the Sierra Club. The Outing does not include carpooling, transportation, or transit to and from the Outing, and I am personally responsible for all risks associated with this travel. This does not apply to transportation provided by the Sierra Club during the Outing. If I decide to leave early and not to complete the Outing as planned, I assume all risks inherent in my decision to leave and waive all liability against the Sierra Club arising from that decision. Likewise, if the leader has concluded the Outing, and I decide to go forward without the leader, I assume all risks inherent in my decision to go forward and waive all liability against the Sierra Club arising from that decision. This Agreement is intended to be as broad and inclusive as is permitted by law. If any provision or any part of any provision of this Agreement is held to be invalid or legally unenforceable for any reason, the remainder of this Agreement shall not be affected thereby and shall remain valid and fully enforceable. To the fullest extent allowed by law, I agree to WAIVE, DISCHARGE CLAIMS, AND RELEASE FROM LIABILITY the Sierra Club, its officers, directors, employees, agents, and leaders from any and all liability on account of, or in any way resulting from Injuries and Damages, even if caused by negligence of the Sierra Club its officers, directors, employees, agents, and leaders, in any way connected with this Outing. I further agree to HOLD HARMLESS the Sierra Club, its officers, directors, employees, agents, and leaders from any claims, damages, injuries or losses caused by my own negligence while a participant on the outing. I understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrators and assigns, and includes any minors accompanying me on the Outing. I have read this document in its entirety and I freely and voluntarily assume all risks of such Injuries and Damages and notwithstanding such risks, I agree to participate in the Outing. Participant Name: Signed: Date: *If you are a minor (under age 18), your parent or legal guardian must sign this Agreement on your behalf. I, the parent or guardian of the minor named below, agree and consent to the foregoing Agreement and give my permission for him/her to go on the Outing. I further consent and allow the Outing leader or bearer of this document to administer first aid and/or secure medical attention for the minor as the Outing leader or document bearer deems proper. I understand that efforts will be made to contact me if medical treatment should be needed. I will ensure that the minor will bring any necessary medications with him/her on the trip. Name and Age of Minor: (Please Print) (Age) Signature of Parent or Guardian: X Date: Sign Here

5 Información sobre participante de excursiones Inner City Outings Destino del viaje: Fruita, CO area (including Highline Lake, 18 Road, Kokopeli Trails, and Colorado National Monument) Fecha(s) del viaje: 5/30/15 a 6/1/15 Hora de salida: 8:00 a.m. (5/30) Hora aproximada de regreso: 8:00 p.m. (6/1) Lugar de partida: Nombre del participante Escuela Secundario de Casey Nombre del padre o guardián legal: Dirección: Ciudad, Estado, Código postal: Teléfono de la casa: ( ) - Otro teléfono: ( ) - Aseguradora: Número de la póliza: Médico familiar: Teléfono: ( ) - Información sobre el participante en el viaje Fecha de nacimiento: / / Altura Peso Escriba cualquier condición médica especial que le afecte al participante (asma, lentes de contacto, etc.) o alergias (a alimentos, medicinas, insectos, etc.): Escriba todas las medicinas que está tomando, incluso en inhaladores. Por favor especifique la dόsis y el horario. Además, asegúrese de llevar suficiente medicina para que le dure todo el viaje. Firme Aquí Permiso de parientes/guardianes legales para publicar Sí No Yo autorizo el uso de fotos, palabras escritas, o discursos por mi hijo/hija para que aparezcan en cualquier tipo de comunicación (por ejemplo, radio, televisión, periódicos, folletos, o páginas de Internet) para poder promover el programa de Inner City Outings. Si usted no está de acuerdo que se publique la foto etc. de su hijo/hija, su hijo/hija siempre podrá participar en la excursión de Inner City Outings. X Firma del padre o guardián legal Fecha

6 Reconocimiento de responsabilidad del participante en la excursión, aceptación expresa de riesgos, liberación de responsabilidad civil y permiso para participar Comprendo que durante mi participación en esta excursión de Sierra Club, podría estar expuesto a diversos riesgos y peligros previstos e imprevistos que son inherentes a cada excursión y que no pueden eliminarse sin destruir las condiciones únicas de la excursión. Sin estar limitados a esta lista, los riesgos inherentes podrían incluir los siguientes: lesiones personales graves, daños a bienes personales o muerte ( daños y perjuicios ), por estar expuesto a las vicisitudes del viaje. Sierra Club no ha tratado de contradecir ni minimizar mi concepto sobre los riesgos. Sé que esos daños y perjuicios podrían ocurrir por causas naturales o a consecuencia de las acciones de: otras personas, animales, participantes en la excursión, guías y sus asistentes o terceras personas; y que podrían ocurrir por negligencia o por otras razones. Comprendo que los riesgos de tales daños y perjuicios pueden ocurrir en viajes de diversión, como lo son las excursiones de Sierra Club, y reconozco que debido a la existencia de dichos riesgos, debo ser especialmente cauteloso para protegerme a mí mismo y a quienes me rodeen. También comprendo que durante esta excursión probablemente no tendré a mi disposición medios de rescate, instalaciones médicas o la pericia médica requerida para que se me atienda en caso de daños y perjuicios a los que podría estar expuesto. Para que se considere mi aceptación como participante en esta excursión y para que Sierra Club determine los servicios y los accesorios útiles que podría proporcionar para la excursión, confirmo el conocimiento que tengo de lo siguiente: He leído todas las reglas y condiciones relacionadas con la excursión puestas a mi disposición; reconozco que mi participación está sujeta a la discreción del guía. La excursión oficialmente comienza y termina en el lugar determinado por Sierra Club. La excursión no incluye arreglos de transporte, individual o en grupo, para llegar o para alejarse del lugar de la excursión y yo soy personalmente responsable por todo riesgo relacionado con dicho transporte. Esto no aplica al transporte provisto por Sierra Club durante la excursión. Si decido concluir temprano o no terminar la excursión según los planes, asumo todos los riesgos inherentes a mi decisión de retirarme y libero de responsabilidad a Sierra Club por mi decisión. Igualmente, si el guía decide concluir la excursión y yo decido proseguir sin el guía, asumo todos los riesgos inherentes a mi decisión de proseguir y libero de toda responsabilidad a Sierra Club por mi decisión. Este acuerdo es amplio e incluye toda situación según lo permite la ley. Si se determina que alguna disposición o una parte de una disposición de este acuerdo es inválida o legalmente no susceptible a ejecución o reclamo judicial por razón cualquiera, el resto del acuerdo no resultará afectado y permanecerá en vigor y plenamente susceptible a ejecución. Dentro de los límites permitidos por la ley, acepto RENUNCIAR A RECLAMOS Y LIBERAR DE RESPONSABILIDAD CIVIL A Sierra Club, a sus funcionarios, directores, empleados, agentes y guías por toda responsabilidad civil que ocurra a consecuencia, o como resultado de daños y perjuicios, aunque sean ocasionados por negligencia de Sierra Club, sus funcionarios, directores, empleados y guías, en relación de alguna manera con esta excursión. Además acuerdo que LIBERO DE RESPONSABILIDAD CIVIL a Sierra Club, a sus funcionarios, a los miembros de su junta directiva, a sus empleados, a sus agentes y a sus guías, por todo reclamo, daño, lesión o pérdida ocasionados por mi negligencia durante mi participación en la excursión. Comprendo y mi intención es que al asumir riesgos y liberar responsabilidades, esta acción obligue también a mis herederos, ejecutores de acuerdos, administradores y que aplique e incluya a todos los menores de edad que me acompañen en esta excursión. He leído este documento en su totalidad y libre y voluntariamente asumo todos los riesgos de daños y perjuicios y teniendo en cuenta dichos riesgos, acepto participar en esta excursión. Nombre del participante: Firma: Fecha: Si usted es menor de edad (menor de 18 años), este acuerdo deberá ser firmado a nombre del participante por uno de sus padres o por su acudiente legal. Como padre o acudiente del menor aquí mencionado acepto el acuerdo anterior y doy permiso para que este menor participe en la excursión. Además doy mi consentimiento para permitir que el guía de la excursión o el portador de este documento preste primeros auxilios y/o busque atención médica al menor de la manera que el guía de la excursión o el portador del documento considere apropiado. Estoy al tanto de que se efectuarán esfuerzos para contactarme si es necesario prestar atención médica al menor. Verificaré que el menor lleve consigo todas las medicinas que necesite durante este viaje. Nombre y edad del menor: (En letra de molde, por favor) (Edad) Firma del padre o acudiente: X Fecha: Firme Aquí

7 TRIPS FOR KIDS DENVER THIS FORM MUST BE READ, COMPLETED IN FULL, SIGNED AND GIVEN TO THE TRIPS FOR KIDS DENVER LEADER BEFORE THE PARTICIPANT MAY GO ON THE OUTING. EXPRESS ASSUMPTION OF RISK, RELEASE, INDEMNIFICATION AND COVENANT NOT TO SUE AGREEMENT In consideration for the services of Trips for Kids Denver its outing leaders, officers, agents, and volunteers (collectively referred to herein as " TFKD "), I, on behalf of myself and/or as the parent or guardian of the minor child participating in the TFKD activity, and our heirs, agree as follows: I understand and am aware that hiking, backpacking, rock climbing, mountain biking, swimming, and related activities including, among others, use of TFKD bicycles and other equipment (referred to herein as "Activity"), and transportation to and from such Activity, are HAZARDOUS ACTIVITIES involving INHERENT AND OTHER RISKS of injury to any and all parts of the body. I further understand that injuries in the Activity are a COMMON AND ORDINARY OCCURRENCE, and I have made a voluntary choice for myself and/or the minor child listed below to ACCEPT AND ASSUME ALL RISKS OF INJURY OR DEATH that might be associated with or result from this Activity. To the fullest extent allowed by law, I agree to RELEASE FROM LIABILITY, and to INDEMNIFY AND HOLD HARMLESS TFKD from any and all liability on account of, or in any way resulting from, personal injuries, death or property damage, even if caused by NEGLIGENCE, in any way connected with this Activity. I further AGREE NOT TO MAKE A CLAIM OR SUE FOR INJURIES OR DAMAGES RELATING TO THIS ACTIVITY, even if caused by NEGLIGENCE. I understand and agree that this Agreement is intended to be as broad and inclusive as is permitted by law, and if any portion is held invalid, the balance shall continue in full legal force and effect. I agree that no oral representations, statements or inducements apart from this Agreement have been made. AUTHORIZATION FOR FIRST AID AND MEDICAL TREATMENT I recognize that medical or dental care may be necessary for myself and/or my minor child. I AUTHORIZE TFKD AND THE OUTING LEADER(S) TO RENDER FIRST AID OR EMERGENCY CARE, within the scope of the certification of the outing leader(s). In addition, I authorize TFKD to call for medical or dental care for myself and/or my minor child if, in the opinion of TFKD, medical or dental care is needed. I AGREE TO PAY FOR ALL EXPENSES AND COSTS ASSOCIATED WITH SUCH CARE AND RELATED TRANSPORTATION. In addition, I hereby authorize and consent for any x-ray examination, anesthetic, medical, dental or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and/or emergency staff and/or dentist currently licensed by the state in which treatment is given and the staff of any acute general hospital holding a current license to operate a hospital from the State of Colorado Department of Public Health or the equivalent agency in another state. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the physician in the exercise of his best judgment may deem advisable. It is understood, medical condition allowing, that effort shall be made to consult the undersigned prior to rendering the treatment to the patient, but that any of the above treatment will not be withheld if the undersigned is incapacitated or cannot be reached. To accomplish our goals, Trips for Kids Denver frequently sends press releases and photographs to the media (newspaper, radio, television and the internet) and uses photos in our own publications. It is the right of the individual whether or not to consent to the use of his/her photograph and/ or name for the above publicity purposes. I hereby authorize Trips for Kids to use any photos taken of me during Trips for Kids Denver activities. YES NO I HEREBY ACKNOWLEDGE THAT ALL THE INFORMATION I HAVE PROVIDED ON PAGE ONE AND PAGE TWO OF THIS AGREEMENT IS TRUE, CORRECT AND COMPLETE. I AGREE TO UPDATE PAGE 2 OF THIS AGREEMENT AS NECESSARY. I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ, UNDERSTOOD AND ACCEPTED EACH OF THE ABOVE PROVISIONS, AND VOLUNTARILY SIGNED THIS AGREEMENT. [PRINT NAME OF PARTICIPANT] [ AGE] [NAME OF PARENT/GUARDIAN OF MINOR PARTICIPANT] X Date: [SIGNATURE OF PARTICIPANT OR PARENT/GUARDIAN OF MINOR PARTICIPANT] YOU MUST ALSO READ AND COMPLETE PAGE TWO OF THIS AGREEMENT p.1

8 PARTICIPANT'S EMERGENCY MEDICAL INFORMATION This information may be used for more than one outing. You must inform the outing leader if any of this information changes from outing to outing. 1. Participant's Name Parent's/Guardian's Name (of minor participant) Address: Phone: Birth date: Date of most recent tetanus toxoid booster: 2. Allergies to drugs, foods, insect bites, etc.: 3. List all medications for which the participant currently holds a prescription and indicate which ones the participant will be taking during outing(s): 5. List all medical conditions of which the outing leader should be aware or which may affect the participant's ability to participate in activities (such as asthma, heart disease, diabetes or neuromuscular or skeletal impairment): Family Physician (Name, Address, Phone): Insurance Company: Policy# List the persons we should call in case of an emergency. We will try to contact them in the order that they are listed. 1. Name Relationship Daytime Phone Evening Phone 2. Name Relationship Daytime Phone Evening Phone 3. Name Relationship Daytime Phone Evening Phone YOU MUST ALSO READ AND SIGN PAGE ONE OF THIS AGREEMENT p.2

9 TRIPS FOR KIDS DENVER ESTE FORMULARIO DEBE SER LEIDO, LLENADO A CABALIDAD, FIRMADO Y ENTREGADO AL LIDER DE TRIPS FOR KIDS DENVER ANTES QUE EL PARTICIPANTE PUEDA IR EN LA EXCURSION INDICADA ABAJO. EXCURSION(ES) LIDER(ES) ACUERDO EXPRESO DE ASUNCION DE RIESGO, EXONERACION, INDEMNIFICACION Y ACUERDO DE NO DEMANDAR En consdieracion por los servicios de Trips for Kids Denver, sus lideres de excursiones, oficiales, agentes y voluntarios (colectivamente referidos aqui como TFKD ), yo, en nombre de mi mismo y/o como el padre de familia o guardian del nino menor participante en la actividad de TFKD, y nuestros herederos, acordamos a lo siguiente: Yo entiendo y estoy anuente que escalar (hiking), caminatas con mochilas (backpacking), navegacion en rios (river rafting), navegacion en canoa, manejar bicicleta en montana, nadar y actividades relacionas que incluyen, entre otras, usar el equipo de TFKD, tales como estufas de campamento, fogatas, cuchillos, tiendas de campana, mochilas (backpacks), balsas, canoas y bicicletas (referidas aqui como Actividad ), y transporte a y de tal Actividad, son ACTIVIDADES PELIGROSAS que involucran RIESGOS INHERENTES Y OTROS de herida a alguna o todas las partes del cuerpo. Tambien entiendo que las heridas en las Actividades son una OCURRENCIA ORDINARIA Y COMUN, y que he hecho una decision voluntaria por mi mismo y/o el nino menor indicado abajo y ACEPTO Y ASUMO TODOS LOS RIEGOS DE ENFERMEDAD, HERIDA O MUERTE que pudieran estar asociados con o resultar de esta Actividad. A la mayor extension autorizada por la ley, estoy de acuerdo en EXONERAR DE CUALQUIER RESPONSABILIDAD y de INDEMNIFICAR Y MANTENER ILESO al TFKD de cualquier y toda responsabilidad con respecto a, o en cualquier forma resultante de, heridas personales, muerte o dano de propiedad, aun cuando causado por NEGLIGENCIA, en cualquier forma conectada con esta Actividad. Ademas, ACUERDO NO HACER NINGUN RECLAMO O DEMANDA POR HERIDAS O DANOS RELACIONADOS CON ESTA ACTIVIDAD, aun si fueran causados por NEGLIGENCIA. Entiendo y acuerdo que este Acuerdo tiene la intencion de ser tan amplio e inclusivo como lo permita la ley, y si alguna porcion fuera invalida, el balance continuara en fuerza completa legal y efecto. Estoy de acuerdo en que aparte de este Acuerdo no se han hecho presentaciones orales, declaraciones o inducimientos. AUTORIZACION PARA TRATAMIENTO MEDICO Y DE PRIMEROS AUXILIOS Reconozco que cuidado medico o dental puede ser necesario para mi y/o mi nino menor. Por este medio NOMBRO AL LIDER DE EXCURSION CERTIFICADO DE TFKD COMO GUARDIAN TEMPORAL DE MI HIJO MENOR participante en la excursion para los propositos de hacer arreglos para o la provision de asistencia medica. Por este medio AUTORIZO AL LIDER DE TFK PARA QUE HAGA ARREGLOS O PROVEA A MI MISMO O A MI NINO MENOR CON PRIMEROS AUXILIOS, CUIDADO DE EMERGENCIA O CUALQUIER OTRA ASISTENCIA MEDICA en el caso de accidente, enfermedad o herida, incluyendo y sin limitacion, evacuacion por helicoptero, servicio de ambulancia, medicamento, hospitalizacion y cirugia, y a ejecutar tales formularios, consentimientos y exoneraciones como sea necesario, apropiado o deseable bajo las circunstancias. Ademas, autorizo al lider de la excursion de TFKD a delegar la autoridad otorgada por este medio a tales otras personas como el o ella en su sola discrecion pueda seleccionar. ESTOY DE ACUERDO EN PAGAR POR TODOS LOS GASTOS Y COSTOS ASOCIADOS CON TAL CUIDADO Y TRANSPORTE RELACIONADO. POR ESTE MEDIO RECONOZCO QUE TODA LA INFORMACION QUE HE PROVEIDO EN LA PAGINA UNO Y PAGINA DOS DE ESTE ACUERDO ES VERDADERA, CORRECTA Y COMPLETA. ESTOY DE ACUERDO EN ACTUALIZAR LA PAGINA DOS DE ESTE ACUERDO SEGUN SEA NECESARIO. POR ESTE MEDIO RECONOZCO QUE HE LEIDO EN SU TOTALIDAD, ENTENDIDO Y ACEPTADO CADA UNA DE LAS PROVISIONES ANTERIORES, Y VOLUNTARIAMENTE FIRMADO ESTE ACUERDO. Para realizar nuestras metas, Trips for Kids Denver envia comunicados y fotografias a los periodicos, radio, television, el internet, y usamos fotos en nuestras publicaciones. Es un derecho individuo decidir si da ó no da permiso para usar fotos de si mismo ó su nombre en las actividades mencionadas para publicar a Trips for Kids Denver. Con esto, yo autorizo que Trips for Kids puede usar cualquier foto tomada de mi durnate participacion en actividades de Trips for Kids Denver. SI NO Nombre del Participante Edad Nombre del Padre de Familia o Guardian Del Participante X Firma del Participante o Padre de Familia/Guardian del Menor Participante Fecha PAGINA UNO

10 INFORMACION MEDICA DE EMERGENCIA DEL PARTICIPANTE Esta informacion puede ser usada para mas de una excursion. Usted debe informar al lider de la excursion si alguna de esta informacion cambia de excursion a excursion. Nombre del Participante Nombre del Padre de Familia o Guardian (del Menor Participante) Direccion Telefono Fecha de Nacimiento Fecha de la vacuna mas reciente Alegias a Medicamentos, Comidas, Picadas de Insectos, Etc.: Liste todos los medicamentos para los cuales el participante actualmente tiene prescripcion e indique cuales el participante estara tomando durante la(s) excursion(es): Liste todas las condiciones medicas de las cuales el lider de la excursion debe saber o las cuales afectan la habilidad del participante de participar en actividades (tales como asma, enfermedades del corazon, diabetes o impedimiento neuromuscular o squeletal). Doctor de la Familia Nombre Direccion Telefono Compania de Seguro Medico Numero de Poliza Lista de personas que debemos llamar en caso de una emergencia. Trataremos de contactarlos en el orden en que estan nombrados abajo. 1. Nombre Relacion al Participante Telefono en el Dia Telefono en la Noche 2. Nombre Relacion al Participante Telefono en el Dia Telefono en la Noche 3. Nombre Relacion al Participante Telefono en el Dia Telefono en la Noche USTED TAMBIEN DEBE LEER Y FIRMAR LA PAGINA UNO DE ESTE ACUERDO PAGINA DOS 3/01 permspanish 2001 Ride Disk#1

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