HIGH RISK ACTIVITY PERMISSION FORM

Girl Scouts of Kentucky's Wilderness Road

2277 Executive Drive, Lexington, KY 40505 859-293-262;1800-475-2621
HIGH RISK ACTIVITY PERMISSION FORM
This High Risk Activity Permission Form is used for permission to participate in certain activities at events sponsored by Girl Scouts of Kentucky Wilderness Road (GSWRC or the "Council" Not all age groups will be involved with specific activities because of Safety Activity Check Points restrictions. Please write in ink, not pencil if completing a hard copy.
Event or if for the year please put "For year of 202_"
Date of Event or today's date if for year.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Participant Name(s)
Phone Number
Format: (000) 000-0000.
Address
City, State Zip
Email Address
example@example.com
Troop Number and Age Level (DA, BR, JR, CA, SR, AM, or Adult
Age(s) at time of event
ACKNOWLEDGEMENT OF INHERENT RISK, WAIVER AND RELEASE OF LIABILITY. I, the Participant, acknowledge and understand that there are risks inherent in certain activities in Council-sponsored events (the "Activities" or "High Risk Activities" Activities may include, but are not limited to: horseback riding, swimming, canoeing, sailing, white water rafting, rappelling, rock climbing, prusiking and caving. Activities may also take place on our Team's Challenge Course and Climbing Tower. I understand and acknowledge that my participation in such Activities involves risks and dangers which include, without limitation, the potential for serious bodily injury, permanent disability, paralysis, and loss of life; loss of or damage to equipment or property; equipment failure; situations beyond the immediate control of the GSWRC; and other risks and dangers which may or may not be readily foreseeable or are presently unknown. I hereby expressly assume all such risks and responsibility for any damages, liabilities, losses, injuries, or expenses that I incur as a result of my participation in the Activities. I, Participant, for myself, my heirs, executors, administrators, parent/guardian, and any persons or entities connected with me, hereby release and discharge GSWRC, its successors, predecessors, assigns, affiliates, the respective employees, officers, directors, or agents of it or them, and all other individuals or entities who or that are or might be connected with it or them or found to be jointly or severally liable with it or them ("Released Parties") from any and all charges, actions, causes of action, suits, sums of money, warranties, covenants, claims and demands, losses, expenses or attorney's fees for any damages or injuries arising in any way out of my participation in the Activities, including but not limited to claims for liability caused in whole or in part by the negligence of the Released Parties.
Signature of Participant if 18 years old or over
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Participant if 18 years old or over FOR MINOR PARTICIPANTS. As the parent or guardian of the minor participant identified above, I understand and hereby accept and agree to all of the terms and conditions described above on behalf of the minor in connection with the minor's participation in the Activities. I authorize and grant permission for the minor participant identified above to participate in all Activities.
Signature of ParentGuardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Required for participant under age 18
High Risk Activity Permission Form I hereby authorize Girl Scouts Wilderness Road Council (GSWRC), its personnel, and the medical provider(s) selected by GSWRC to secure and/or administer emergency and/or non-emergency medical treatment, including but not limited to emergency care, hospitalization, other routine care; administering non-prescription and/or prescription drugs; prescribing drugs; ordering X-rays, tests or procedures, or other treatment; and any other medical procedures or related transportation arrangements which may be necessary for my daughter/ward or, if I am a Participant 18 years of age or older, for me.

I understand that GSWRC will attempt to contact the parent or guardian of a minor Participant, and/or any other individual identified as an emergency contact, as soon as practicable in the event of an emergency. However, I understand that this consent is given in advance of any accident, injury, or illness giving rise to the need for emergency medical treatment. I authorize GSWRC to release any medical records necessary for insurance purposes. I understand and agree that I am solely responsible for any costs, fees, payments or expenses associated with emergency and/or non-emergency medical treatment.

I further understand and agree that GSWRC, its affiliates, and their respective employees, officers, directors and agents, expressly disclaim responsibility, and shall have no liability, for any charges, actions, causes of action, suits, sums of money, warranties, covenants, claims and demands, losses, expenses or attorney's fees for any damages or injuries arising in any way out of emergency or non-emergency medical treatment provided by GSWRC, its personnel, and/or any medical provider selected by GSWRC.
Signature of Participant if 18 years or older
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print ParentGuardians Name
Print Minor Participants Name
ParentGuardians Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: