Denver, CO SERVER REGISTRATION Husband's name * Husband's last name * Husband's Email* Husband's date of birth * Husband's Shirt Size * —Please choose an option—XSSMLXLXXLXXXL Wife's name * Wife's last name * Wife's Email* Wife's date of birth * Wife's Shirt Size * —Please choose an option—XSSMLXLXXLXXXL Address* Phone * Emergency phone number * Is the Wife pregnant? * —Please choose an option—YesNo Do you suffer from a chronic disease? * —Please choose an option—YesNo Specify your disease * ABOUT MEDICAL INSURANCE IN THE REM FRONT RANGE READ CAREFULLY MEDICAL/MEDICAL INSURANCE: You can participate in the REM Front Range even if you don't have medical/accident insurance, but it will be your responsibility to cover medical expenses in case of an accident. Take note that some Insurance companies can offer coverage for medical/accident expense for specific periods of time, thus you can purchase medical coverage for the dates of the event. Please consult a certified Insurance agent. Next Section: Waiver Next Through this statement I certify the following: 1- That I am the REM participant for whom this form is being completed OR THAT I am the parent or guardian or have legal custody of the participant if the participant is a minor. 2- I am not signing the following forms on behalf of someone else unless I am completing those forms on behalf of a minor of whom I am the parent or of whom I have legal custody. 3- I have the legal authority to sign such forms These forms and all their sections comply with the Security Procedures and statutes specified in the State Statutes and any other State or Federal Law regarding digital signatures. I Agree* If you agree, continue or leave the page. BackNext LEGENDARY – RETO DE EMPODERAMIENTO MATRIMONIAL WAIVER, DISCLAIMER, INDEMNITY AND CONSENT FOR MEDICAL CARE 1. Voluntary participation. I understand and confirm that my participation in LEGENDARIOS, presented and organized by Front Range, is based on my voluntary wish. 2. Risk Identification. I understand that my participation in LEGENDARIOS may involve risks of injury and loss, both to the person and to the property. I also understand that the risk of injury may include, but is not limited to, the possibility of temporary or permanent disability or death. I understand that this waiver, release of liability, indemnification, and consent for medical care is intended to address all risks of any kind associated with my participation in any aspect of LEGENDARIOS, or during the time that I will be involved in LEGENDARIOS, including risks created by the actions, omissions, carelessness or negligence on the part of LEGENDARIOS Front Range or its executives, pastors, employees, agents, volunteers, successors or assignees of Front Range, including, but not limited to, risks created by the following situations: a. The use and status of the different modes of transport, premises, facilities, equipment, and to and from and during the LEGENDARY event; b. The insufficiency or lack of policies, rules, or regulations for the LEGENDARIES; c. The failure of LFRC or its representatives to foresee or protect me from the actions, omissions or negligence of any person, animal or another natural phenomenon, or the reckless, willful, or criminal misconduct of persons who are not affiliated with LFRC; The insufficiency or unavailability of medical facilities or treatment; or d. The insufficiency or lack of LFRC or its representatives. 3. Assumption of Risk. I understand that LEGENDARIOS will be an extreme physical challenge event, in a natural outdoor setting, without the protections provided by the elements. I assume all risks, known and unknown, foreseeable and unforeseeable, related in any way to my participation in LEGENDARIOS. I accept personal responsibility for any situation, injury, loss, or damage related in any way to my participation in LEGENDARIOS. The following is a list of risks, however, this list is not intended to be exhaustive: to. Acts of God or the elements of nature such as weather changes, extreme temperatures, rain, thunder and lightning, hypothermia and heat exhaustion; b. Injuries associated with hiking, mountaineering, hiking, kayaking, canoeing, and physical activity, such as impacts with rocks and trees, physical exhaustion, and drowning; c. Exposure to wild plants, wild animals, and the bites or stings of animals including insects, snakes, bears, bobcats, and wild boars (etc). 4. Release of liability. Libero LEGENDARIOS, FR. and its representatives from any liability and I waive any claim for civil liability, injury, unavailability, or rebellion to continue with the activity (REM) for any reason, loss, damage, or expense, including attorneys' fees, related in any way to my participation in LEGENDARIOS, whether or not caused in whole or in part by the negligence or other fault of LEGENDARIOS, or LEGENDARIOS FRONT RANGE or their representatives (a "claim"). 5. Compensation. I agree to indemnify and hold LEGENDARIOS FRONT RANGE and its representatives without damage or harm related to a claim, or any expense, including attorney's fees (cost of defense against any claim that I could personally make, or that can be made in my name) and that has already been released from liability through this document, related in some way to a claim. 6. Binding effect. This instrument will be binding on my relatives, personal representatives, heirs, beneficiaries, relatives, and assignees, and will benefit LEGENDARIOS FRONT RANGE and its representatives. 7. Divisibility. If any provision (or part of any provision) of this instrument is held invalid or unenforceable, such provision will be enforceable in part, to the extent permitted by law, and such invalidity or unenforceability will not otherwise affect any other disposition of this instrument. 8. Applicable law. Because LEGENDARIOS, will be carried out in the State of Colorado, and to offer security according to the law and applied in the construction of this instrument, it will be governed, interpreted, and executed by the law of the State. from Colorado. 9.Marketing Authorization. LEGENDARIOS FRONT RANGE and its representatives may record each LEGENDARIOS participant, at different times of the LEGENDARIOS event through videotapes, audiotapes, or photography, and may use the participant's name, voice, or testimony without restrictions for the future. for promotional purposes of LEGENDARIOS / LEGENDARIOS FRONT RANGE unless otherwise stated in writing. 10. Consent for medical treatment. I authorize LEGENDARIOS FRONT RANGE and its representatives, if present, to provide me, through medical personnel of their choice, with usual medical assistance, transportation, and emergency medical services if required or transportation or services as a result of an injury or damage related to my participation in the LEGENDARIES. This consent is given before any specific diagnosis, treatment, surgery, or medication, and is given to provide specific authorization and consent for medical/dental treatment and care on my behalf. This consent does not impose an obligation on LEGENDARIOS / FRONT RANGE and its representatives to provide such assistance, transportation, or service. 11. Abstinence: I am not bringing any kind of drugs, alcohol, or cigarettes. If I consume any of these things during the activity, I agree to be sent immediately to my place of residence and my emergency contacts will be notified. The return to my place of residence, if I do not comply with this provision, will be an expense fully paid by myself or by my parents or legal guardians. 12. Health insurance: I certify that I have personal health insurance for the provision of medical services for myself and that it will provide coverage for the duration of LEGENDARIOS. This coverage will fully insure me for the duration of the LEGENDARIOS event. If I do not have coverage, then I agree to insure or personally cover the related expenses. If I am traveling internationally, my health insurance includes full coverage in the foreign countries where I am going to travel, without territorial limitations. I understand that LEGENDARIOS FRONT RANGE and its representatives do not provide any health plans and that all medical expenses are my responsibility. THIS IS A WAIVER, DISCLAIMER, INDEMNITY, AND CONSENT. I HAVE READ THIS DISCLAIMER, RELEASE OF LIABILITY, INDEMNITY, AND CONSENT. I UNDERSTAND THAT I HAVE WAIVED SUBSTANTIAL RIGHTS IN SIGNING IT. I AM SIGNING THIS WAIVER, RELEASE OF LIABILITY, INDEMNITY, AND CONSENT ON A VOLUNTARY BASIS. Write your Initials (Husband) * Write your Initials (Wife) * Husband signature* Wife signature* By placing your initials and signature above, you are accepting each of the points of the Waiver Form. An email with a copy of this waiver will be sent upon registration. Next Section: "Medical Condition Report" MEDICAL CONDITION REPORT Extreme Character Challenge - Medical Condition Report VACCINES: LEGENDARIOS FRONT RANGE recommends that the participant have up-to-date tetanus shot and all other shots are up-to-date. Have you been vaccinated against covid19?* —Please choose an option—YesNo Do you have or have you ever had any of the following?* 1.Food Allergies —Please choose an option—YesNo 2. Allergy to Penicillin or another drug (enter name below) —Please choose an option—YesNo 3. Allergy Sting or bite of insects —Please choose an option—YesNo 4. Allergy to poison sumac, oak, or ivy —Please choose an option—YesNo 5. Previous operations or serious surgeries —Please choose an option—YesNo 6. Vital Current Medications (List Below) —Please choose an option—YesNo 7. Diabetes —Please choose an option—YesNo 8. Convulsions —Please choose an option—YesNo 9. Fainting —Please choose an option—YesNo 10. Heart problems —Please choose an option—YesNo 11. Eating disorders or stomach problems —Please choose an option—YesNo 12. Respiratory problems —Please choose an option—YesNo 13. Psychiatric Care —Please choose an option—YesNo 14. Take medicine for depression or behavior control —Please choose an option—YesNo Please explain if you have selected YES to any of the questions above Leave blank if all answers above are "no" Special diet: (Name) Please note: Special diets will not be provided at the event by the institution hosting LEGENDARIOS unless medically necessary, and in which case the participant must bring their own food supply. Please explain any other important medical information that a medical provider needs to be aware of during their time at LEGENDARIOS – Reto Extremo de Carácter I ACKNOWLEDGE THAT THE ABOVE INFORMATION HAS NOT BEEN PROVIDED WITH THE INTENTION OF PLACING OR ASSIGNING LIABILITY TO BLO / CCPP FOR MAINTAINING THE WELFARE OF THE PARTICIPANT, HOWEVER, THIS INFORMATION IF IT IS BEING CAPTURED TO SHARE TO ANY EMERGENCY SUPPLIER, IN CASE OF EMERGENCY RECOGNITION IN CASE TOGETHER WITH THIS MEDICAL CONDITION REPORT, I HAVE SIGNED THE WAIVER OF LIABILITY, INDEMNITY AND CONSENT TO MEDICAL CARE, WHICH IS PART OF THIS DOCUMENT (insert your initial) I accept the terms and conditions Write your Initials (Husband) * Write your Initials (Wife) * Back