1- This registration contains sections that will require electronic signatures that can only be placed by the participant of the TOP. If you are filling out this form on behalf of someone else who is older than 18 years of age (adult), it is strictly necessary that the participant is with you while filling out the form so he is able to place the "e-signatures". If you are filling out this form on behalf of a minor, you must be the parent or the legal guardian of the minor for whom this form is being filled out.
The participant (+18 age) is present to digitally sign this form.*
I agree to be reimbursed with the 50% of payment if the participant is not able to go.*
E-mail of the person who is filling out this form*
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About Colorado weather
Payments
I accept*
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Participant name*
DOB*
TOP Date:* August 1-4 2024 June 19-22 2025
Email:*
Address*
Phone:*
Marital status*
Single Married Divorced United Widowed Separated
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Shirt size:*
(2XS) 2 Extra Small (XS) Extra Small (S) Small (M) Medium (L) Large (XL) Extra-Large (2XL) 2 Extra-Large (3XL) 3 Extra-Large (4XL) 4 Extra-Large (5XL) 5 Extra-Large
Religion:
Emergency contact information.*
Contact Name:
Contact Email:
Country Contact:
Contact Phone:
ABOUT MEDICAL INSURANCE IN THE TOP FRONT RANGE
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Next Section: Waiver
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Through this statement I certify the following:
1- That I am the TOP 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
I Agree* If you agree, continue or leave the page.Back Next
LEGENDARY – TRACK OUTDOOR DE POTENCIAL WAIVER, DISCLAIMER, INDEMNITY AND CONSENT FOR MEDICAL CARE 1. Voluntary participation. 2. Risk Identification. 3. Assumption of Risk. 4. Release of liability. 5. Compensation. 6. Binding effect. 7. Divisibility. 8. Applicable law. 9.Marketing Authorization. 10. Consent for medical treatment. 11. Abstinence: 12. Health insurance: 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. Initials* Signature* Next Section: "Medical Condition Report" MEDICAL CONDITION REPORT Extreme Character Challenge - Medical Condition Report VACCINES: Have you been vaccinated against covid19?* —Please choose an option— Si No Do you have or have you ever had any of the following?* 1.Food Allergies —Please choose an option— Yes No 2. Allergy to Penicillin or another drug (enter name below) —Please choose an option— Yes No 3. Allergy Sting or bite of insects —Please choose an option— Yes No 4. Allergy to poison sumac, oak, or ivy —Please choose an option— Yes No 5. Previous operations or serious surgeries —Please choose an option— Yes No 6. Vital Current Medications (List Below) —Please choose an option— Yes No 7. Diabetes —Please choose an option— Yes No 8. Convulsions —Please choose an option— Yes No 9. Fainting —Please choose an option— Yes No 10. Heart problems —Please choose an option— Yes No 11. Eating disorders or stomach problems —Please choose an option— Yes No 12. Respiratory problems —Please choose an option— Yes No 13. Psychiatric Care —Please choose an option— Yes No 14. Take medicine for depression or behavior control —Please choose an option— Yes No Please explain if you have selected YES to any of the questions above Special diet: (Name) Please explain any other important medical information that a medical provider needs to be aware of during their time at LEGENDARIOS – TRACK OUTDOOR DE POTENCIAL 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* Back