Caregiver - Liability & Release / Youth Health

Agreement For Minor Participants

1. Name of Youth *This question is required.

2. Please type minor participant’s birth date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. Name of Caregiver *This question is required.

GUNNISON/HINSDALE YOUTH SERVICES, INC.
ACKNOWLEDGMENT AND ASSUMPTION OF RISKS AND
RELEASE AND INDEMNITY AGREEMENT
For Minor Participants

For the purpose of this form, ‘Caregiver’ will refer to parent(s) and/or legal guardian(s)

INTRODUCTION

Please read this entire Acknowledgment and Assumption of Risks and Release and Indemnity Agreement (“Agreement”) carefully before signing. For participants under 18 years of age (sometimes “minor” or “child”), one of the participant’s caregiver or both if available (collectively “caregivers”) must sign. In consideration of the services of Gunnison/Hinsdale Youth Services, doing business as Gunnison Valley Mentors or Gunnison Country Partners (alternatively, “GVM”), and its officers, directors, employees, volunteers, agents, representatives, successors, assigns, independent contractors, and all persons or entities affiliated with it, including the owners of permissively used private property (collectively “Gunnison Valley Mentors” or “GVM”), in allowing my child to participate, I acknowledge and agree as follows:

ACTIVITIES, RISKS AND ACKNOWLEDGMENT AND ASSUMPTION OF RISKS

Participating in any activity includes risks. Gunnison Valley Mentors pairs youth (“Mentees”) with adult mentors (“Mentors”) to build one-to-one mentoring relationships that enrich the lives of the youth and promote healthy growth. Mentors and Mentees participate in a variety of activities based on the interests of the Mentee and Mentor. Activities typically take place in Colorado, either on or off Gunnison Valley Mentors premises. While many activities only involve the Mentor and Mentee, some activities may be conducted or led by Gunnison Valley Mentors staff, affiliates, contractors, or others.
Activities may include, but are not limited to: crafts; cooking; hiking; biking; skating; downhill skiing; Nordic (cross-county) skiing; swimming; fishing; interactive games; indoor and outdoor sporting activities, such as hockey, basketball, baseball, soccer, and tennis; socializing; and transportation in vans, buses, and other vehicles to and from activities or otherwise. Occasionally, Gunnison Valley Mentors may organize activities such as whitewater rafting, rock climbing, or out-of-town trips. Also, it is very important for you to know that the Gunnison Valley Mentors liability policy maintained by GVM specifically excludes coverage for certain designated “high risk” activities. The following activities may be specifically excluded from GVM’s insurance coverage and are not a permitted activity:

Bungee Jumping
Equestrian
Fencing
Martial Arts
Parachuting
Rock Climbing
Scuba Diving
Skydiving
Air Show
The use, handling, distribution or sale of fireworks or any similar explosive device or material
Rifle Range
Out of Bounds or Backcountry Skiing/Snowmobiling
Surfing
High Ropes/Climbing Towers
Trampolines/Bounce Houses
Water Skiing/Wakeboarding/Water Tubing
Rodeo Events (as a Participant)

I acknowledge that the inherent and other risks, hazards and dangers (collectively referred to in this Agreement as “risks”) of these activities can, although rarely, cause injury, damage, death or other loss to participants or others. Caregivers give permission for their child to participate in all Gunnison Valley Mentors activities and agree to discuss the nature of these activities and risks with their child. The following describes some, but not all of those risks:

Risks present in an outdoor environment. Because Gunnison and Hinsdale Counties are located in a high-elevation, rural part of Colorado, even mild activities such as walking on an in-town trail involve possible risks. Participants’ travel may be subject to storms, including rain, snow, lightning, and strong winds; avalanches; fast moving rivers or other water bodies; falling or slippery rocks; extremely hot or cold weather or water and rapid and unpredictable weather changes; mudslides; flooding or flash floods; falling or fallen timber; wildland fires; stinging, venomous and/or disease carrying animals, insects or microorganisms; poisonous plants; wild or domestic animals, and other natural or man-made hazards. Hazards (both on land and above and below water level) may not be marked or visible and weather is always unpredictable.

Risks associated with any outdoor or athletic activity. These risks include the risk that a participant may overestimate his or her abilities or fitness; be inattentive; lose control and trip or fall or collide with others, the ground, rocks, trees, or sporting equipment, or encounter other water/terrain/ road/trail hazards; be hit by balls, pucks, sticks, or other sporting equipment; not understand the functioning of, or misuse, the equipment; fail to negotiate steep, uneven or difficult terrain; not control his or her speed; or experience equipment malfunction.

Risks involved in judgment and decision making. These risks include the risk that the participant, a Gunnison Valley Mentors staff member, volunteer, contractor or other person may misjudge the participant’s (or others) capabilities, health or physical condition, or misjudge some aspect of travel, instruction, medical treatment, weather, terrain, water conditions or water level, or route location.

Personal health and participation risks. Participant’s mental, physical or emotional condition (including use or abuse of alcohol or any prescription or non-prescription drugs), disclosed or undisclosed, known or unknown, combined with participation in these activities includes risks. Although Gunnison Valley Mentors personnel will review participant’s submitted health and medical information, Gunnison Valley Mentors cannot anticipate or eliminate risks or complications posed by participant’s mental, physical (including fitness level) or emotional condition.

Infectious disease risks. Participants may be exposed to infectious diseases spread by both animals and humans. Human borne diseases include COVID-19, which is highly contagious and whose transmission and other characteristics are poorly understood by the medical and public health fields. Animal borne diseases include Lyme’s Disease, West Nile Virus, Hantavirus, and Rocky Mountain Spotted fever.

Equipment risks. The risk that equipment used in an activity may be misused, or may break, fail or malfunction. This includes participant’s personal equipment, Gunnison Valley Mentors equipment or other equipment. Participants choosing to bring and use their personal equipment assume full responsibility, along with parents of a minor, for choosing appropriate equipment and for the fit and condition of their equipment. Helmets or other safety gear (required or encouraged for some activities) may prevent or lessen injuries in some instances; however, use of safety gear is not a guarantee of safety, and injury can occur even with the use of this gear.

Cooking and crafting risks. Risks include scalding or other burns associated with cooking over a stove; cuts from knives, scissors, or other cooking utensils; exposure to glue, paint, and other crafting materials.

Risks regarding conduct. The potential that the participant, or other participants or third parties may act carelessly or recklessly.

These and other risks may result in participants: falling partway or falling to the ground or into the water; being buried or struck by an avalanche; being struck by, colliding with or impacting objects, people, animals, or the bottom of a water body; experiencing vehicle collision, rollover, or other accident; getting caught or entangled in objects above or below water; reacting to high altitudes, weather conditions, or increased exertion; becoming lost or disoriented; suffering gastro-intestinal complications or allergic reactions or experiencing other problems. These and other circumstances may cause heat or cold related illnesses or conditions (including hypothermia, hyperthermia, cold water immersion, frostbite, or heat exhaustion/stroke); dehydration; hyponatremia; drowning; high altitude sickness; heart or lung complications; broken bones; paralysis or other permanent disability; mental or emotional trauma; concussions; sunburn or other burns; illnesses (including contracting animal/insect borne or contagious diseases); infections; cuts or wounds or other injury, damage, death or loss.

I (Caregiver of a minor participant) acknowledge and agree:

to review and/or complete all required forms or materials received, abide by the terms of those documents, and obey all Gunnison Valley Mentors rules and other policies;

to make good decisions to minimize the risk associated with the above non-permitted activities;

Gunnison Valley Mentors representatives are available should I have further questions about these activities or the associated risks;

to disclose to Gunnison Valley Mentors representatives any mental, physical or emotional condition/s or limitation/s which might affect participant’s ability to participate, and represent that participant is fully capable of participating without causing harm to him or herself or others;

the information provided above is not complete, other unknown or unanticipated activities, risks, and outcomes may exist, and Gunnison Valley Mentors cannot assure participant’s safety or eliminate any of these risks;

if participant is borrowing or using new or used equipment from Gunnison Valley Mentors, the equipment comes “AS-IS,” and Gunnison Valley Mentors disclaims all warranties, express or implied (including any conditions of merchantability or fitness for a particular purpose) regarding the equipment;

Gunnison Valley Mentors occasionally contracts with independent contractors (not its employees or agents) to provide or conduct some services and activities participants may engage in; it does not supervise or control these contractors and is not legally liable or responsible for their conduct. I understand I may independently investigate and assess these contractors, services and activities if I choose to do so;

participant is voluntarily participating with knowledge of the risks. Therefore, participant (and parents of a minor) assumes and accepts full responsibility for participant, for the inherent and other risks (known and unknown, described above or otherwise) of these activities and for any injury, damage, death or other loss suffered by participant (and parents of a minor), resulting from those risks, including the risk of participant’s own negligence or other misconduct.

RELEASE AND INDEMNITY AGREEMENT

Please read carefully. This Release and Indemnity Agreement contains a surrender of certain legal rights. Certain federal land agencies may restrict service providers from seeking releases of liability for negligence, for injuries or other losses occurring while operating under permit on some federal lands. Therefore, except to the extent a court determines these federal restrictions apply to Gunnison Valley Mentors as a matter of law, I (caregiver/s for themselves and for and on behalf of their participating minor child) agree as follows:

to release and agree not to sue Gunnison Valley Mentors, with respect to any and all claims, liabilities, suits or expenses (including attorneys’ fees and costs) (collectively “claim” or “claims”) for any injury, damage, death or other loss in any way connected with my child’s enrollment or participation in these activities, including use of any equipment, facilities, or premises. I understand I agree here to waive all claims I or my child may have against Gunnison Valley Mentors, bind my estate and my child’s estate and any family member/heir/other party bringing claims and agree that neither I, my child, nor anyone acting on my or my child’s behalf, will make a claim against Gunnison Valley Mentors as a result of any injury, damage, death or other loss suffered by me or my child;

to defend and indemnify (‘indemnify’ meaning protect by reimbursement or payment) Gunnison Valley Mentors with respect to any and all claims:

1. brought by or on behalf of me, my child or spouse or my/my child’s other family members, heirs or estate for any injury, damage, death or other loss in any way connected with my/my child’s enrollment or participation in these activities, including use of any equipment, facilities or premises; or

1. brought by a co-participant or any other person for any injury, damage, death or other loss to the extent caused by my/my child’s conduct in the course of participating in these activities, including use of any equipment, facilities or premises.

This Release and Indemnity Agreement includes claims of negligence (but not gross negligence or willful or wanton misconduct), personal injury or wrongful death (including claims related to emergency, medical, drug or health issues, response, assessment or treatment), property damage, loss of consortium, breach of contract, or any other claim.

OTHER PROVISIONS
I (parents of a minor participant) agree that Colorado law (without regard to its conflict of laws rules) governs this Agreement, any dispute I or my child have with Gunnison Valley Mentors, and all other aspects of my or my child’s relationship with Gunnison Valley Mentors, contractual or otherwise, and agree that any mediation, suit or other proceeding must be filed or entered into only in Gunnison County, Colorado. I agree to attempt to settle any dispute (not being settled by discussion) through mediation before a mutually acceptable Colorado mediator. This Agreement is intended to be interpreted and enforced to the fullest extent allowed by law. If any portion of this Agreement is deemed unlawful or unenforceable, it shall not affect the enforceability of the remaining provisions, and those remaining provisions shall continue in full force and effect.

Media Release:
I hereby authorize Gunnison Valley Mentors to use my or my child’s photograph publicly to promote Gunnison Valley Mentors. I understand that the images may be used in print publications, online publications, presentations, websites, social media, and other promotional materials. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Virtual Mentoring Consent
I understand that the virtual mentoring sessions will take place under the guidance, parameters and direction of the Case Manager, Mentor and Caregivers. This might include e-mail, Facetime, video, or Google Hangout as examples. We encourage no social interaction be allowed via social media outlets such as Facebook, Twitter, Instagram, Snapchat, or similar platforms. Please be sure to monitor online communications. Should any issues, challenges or concerns arise during virtual mentoring, I and/or my child will refer to the Case Manager for resolution immediately.

School-Based Mentoring
Release/Receive Information:
I hereby authorize the release of school records and grade information to Gunnison Valley Mentors. By email, Powerschool, IEP or personal contact regarding my son/daughter.

Transportation Release:
I hereby authorize Gunnison Valley Mentors staff to transport my child(ren). To off campus sites to get lunch and other mentoring activities and to return them to the Gunnison Community School.

Emergency Medical Consent:
I give consent for the Mentor or the GVM representative to obtain appropriate emergency medical or dental attention for (child’s/ward’s name), if such attention is required while I am unavailable for contact and if the medical or dental attention cannot wait until contact can be made.

I understand that I should have in place appropriate health insurance coverage for my child/ward if he/she is injured as a result of his/her participation in the GVM program. I understand my child’s health information will be shared with the child’s Mentor.

Caregivers of a minor participant agree:
I have carefully read, understand and voluntarily sign this Agreement and acknowledge that it shall be effective and legally binding upon me, my spouse, participating minor child and other children, and my/my child’s other family members, heirs, executors, representatives, subrogors, assigns and estate. Adult Participant or one or both parents of a minor participant must complete the information and sign below.

Caregiver Signature: I HAVE CAREFULLY READ ALL PARTS OF THIS AGREEMENT; I FULLY UNDERSTAND ITS CONTENTS AND I HAVE SIGNED IT OF MY OWN FREE WILL. I understand that by typing my name where indicated below, I consent to the use of electronic records and signatures in the manner described above, and the electronic storage of such documents. *This question is required.

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Youth Signature: I HAVE CAREFULLY READ ALL PARTS OF THIS AGREEMENT; I FULLY UNDERSTAND ITS CONTENTS AND I HAVE SIGNED IT OF MY OWN FREE WILL. I understand that by typing my name where indicated below, I consent to the use of electronic records and signatures in the manner described above, and the electronic storage of such documents. *This question is required.

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