Return two forms with deposit:  Registration and risk form. 

Deposits are non-refundable but are transferable to another camper for the same week.

NAME_______________________________ Male ___ Female ___ Date of Birth: ______________ Age____

Address______________________________City______________State____ Zip _____

Phone (___)_________________

Type of camp  attending_____________________________Dates _____________________________

Organization you are coming with( if applicable)__________________________________________________

Yes, my child would like to room with a friend (Name) ____________________ *Not always possible but we try

==============================================================================

Staff has permission to give the following medications as needed as instructed on container.

Circle medicine which you approve:

Tylenol or equivalent                          Ibuprophen                     Children’s Advil                      

Tums                    Mylanta       Immodium AD      Pepto Bismol                  Emetrol (nausea)

Allergy/sinus relief medicine                Benadryl (itching, bee stings)                        Calamine lotion (itching)

Nyquil and/or Dayquil (multi-symptom  relief for flu/cold)

==============================================================================

Medicine ordered by doctorto take every day:  Yes____ No ____  If so, what (include inhalers)

Medicine name ____________________    how much________________          how often _____________________

Medicine name ____________________    how much________________          how often_____________________

Medicine ordered by doctorto take as needed:     Yes ____ No ____ If so, what (include inhalers)

Medicine name ____________________    how much________________          how often _____________________

Medicine name ____________________    how much________________          how often_____________________

Does your child take any herbal and/or vitamins daily or as needed?  OR medication ordered from the

doctor that is over the counter? Yes ____ No____If so, what

Medicine name ____________________    how much________________          how often _____________________

What is all listed medicine for: __________________________________________________________

Does your child have ADD or ADHD? If so, are they on medication? Yes ____ (List above) No ____

• All medication must be in the original container from the pharmacy.  Medications must be given to the medical person for administration and a note with written instructions.
• Does Mountain Trails Staff have permission to treat your child for medical needs until a doctor can be reached?  Yes ____ No____  * Our camp has never had a serious injury in the last 20 years.  We’ve had  one emergency room visit for a camper that was not camp related.

Does your child have any allergies? No ____ Yes ____ If so, what ___________________________________

Treatment?__________________________________________________________________________________

= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =

All young people will be given chores while at camp, such as, cleaning up kitchen, cabin, bathroom,

Name_____________________ is physically able to participate in high adventure activities at Mountain Trails Youth Camp.  Activities include horseback riding, low ropes course, hiking and

                                                   physical games.

I ___________________________________________________ (printed name and signature) of physician, PA-C, FNP, or RN

have examined __________________________ on this date ___________________.

                                          Child’s Full  Name______________________________________

In case of emergency Contact: Name__________________________

Relationship____________

Phone numbers(_____)_____________ home  (______)_________________cell 

In case of emergency Contact: Name__________________________

Relationship________________

Phone numbers(_____)_____________ home  (______)____________

_____cell 

In case of emergency Contact: Name__________________________

Relationship ____________________________________________

Phone numbers(_____)_____________ home  (______)_________________cell 

My child can be picked up by relationship_______________

Name_______________________________  Phone ( ______)____________________

Risk Form, Must be signed for camper to participate

“Risk Form”

 Mountain Trails Camp

Requirement of our insurance for your participation in activities with Mountain Trails Youth Ranch

Without this signed form, you will not be allowed to participate in any activities at camp.

Make sure to turn it in with your registration form.

Parent  or Guardian for Child

In consideration of the services of Mountain Trails Youth Ranch and Camp, their agents, staff, cooks, owners, volunteers, participants, board of directors  and all other persons or entities acting in any capacity on their behalf (hereafter collectively referred to as MTYR) hereby agree to release, indemnify and discharge MTYR, on behalf of myself, my spouse, my children, my parents, my heirs, assigns personal representative and estate as follows:

1.  I acknowledge that my child’s ___________________ (name) participation in outdoor activities such as horseback riding, hiking, rock climbing/rappelling, ropes course, high and low, camping, fishing, entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death or damage to myself, to property or to a third party. 

The risks include among other things:  slipping and falling, falling objects, water hazards,exhaustion, exposure to temperature and weather extremes, which could cause hypothermia, hyperthermia, (heat related illnesses or heat exhaustion);  sunburn, dehydration and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; equipment failure and improper lifting or carrying.  There could be risks in transportation since we sometimes transport from one site to another. 

Furthermore, MTYR cooks, staff, volunteers and owners  have difficult jobs to perform.  They seek safety but they are not infallible.  They might be unaware of a participants fitness or abilities.  They might misjudge the weather or other environmental conditions.  They may give incomplete warnings or instructions, and the equipment being used might malfunction.   

1. I expressly agree and promise to accept and assume all of the risks existing in this activity knowing that there are inherent risks in all outdoor activities.  My child’s participation, in this activity, is purely voluntary, and I elect to allow them to participate in spite of the risks. 
2. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless, MTYR from any and all claims, demands, or courses of action, which are in any way connected with my participation in this activity or use of  MTYR’s equipment, horses, or facilities or camping areas, including any such claims which allege negligent acts of omissions of MTYR.
3. Should MTYR or anyone  acting on their behalf, be required to incur attorney fees and costs to enforce this agreement, I agree to indemnify and hold them harmless in all such fees and costs.
4. I certify that I have adequate insurance to cover any injury or damage my child may incur or suffer while participating, or else I agree to bear the costs of such injury or damage myself.  I further certify that I am willing to assume the risk of any medical or physical condition I may have. 
5. In the event that I file a lawsuit against MTYR, I agree to do so solely in the State of Colorado, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state.  I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. 
6. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child’s participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against MTYR or the basis of any claim from which I have released them herein. 
7. I have had sufficient opportunity to read this entire document.  I have read and understand it and I agree to be bound by it’s terms. 

Signature_______________________________  Print name__________________________ Date___________

Address__________________________________________City______________________State_____ Zip________

Phone (_____) ______-___________

Relationship to child, circle one    Parent      Guardian   Other ____________

Currently there are no questions and answers

“Risk Form”

 Mountain Trails Camp

Requirement of our insurance for your participation in activities with Mountain Trails Youth Ranch

Without this signed form, you will not be allowed to participate in any activities at camp.

Make sure to turn it in with your registration form.

Parent  or Guardian for Child

In consideration of the services of Mountain Trails Youth Ranch and Camp, their agents, staff, cooks, owners, volunteers, participants, board of directors  and all other persons or entities acting in any capacity on their behalf (hereafter collectively referred to as MTYR) hereby agree to release, indemnify and discharge MTYR, on behalf of myself, my spouse, my children, my parents, my heirs, assigns personal representative and estate as follows:

1.  I acknowledge that my child’s ___________________ (name) participation in outdoor activities such as horseback riding, hiking, rock climbing/rappelling, ropes course, high and low, camping, fishing, entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death or damage to myself, to property or to a third party. 

The risks include among other things:  slipping and falling, falling objects, water hazards,exhaustion, exposure to temperature and weather extremes, which could cause hypothermia, hyperthermia, (heat related illnesses or heat exhaustion);  sunburn, dehydration and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; equipment failure and improper lifting or carrying.  There could be risks in transportation since we sometimes transport from one site to another. 

Furthermore, MTYR cooks, staff, volunteers and owners  have difficult jobs to perform.  They seek safety but they are not infallible.  They might be unaware of a participants fitness or abilities.  They might misjudge the weather or other environmental conditions.  They may give incomplete warnings or instructions, and the equipment being used might malfunction.   

1. I expressly agree and promise to accept and assume all of the risks existing in this activity knowing that there are inherent risks in all outdoor activities.  My child’s participation, in this activity, is purely voluntary, and I elect to allow them to participate in spite of the risks. 
2. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless, MTYR from any and all claims, demands, or courses of action, which are in any way connected with my participation in this activity or use of  MTYR’s equipment, horses, or facilities or camping areas, including any such claims which allege negligent acts of omissions of MTYR.
3. Should MTYR or anyone  acting on their behalf, be required to incur attorney fees and costs to enforce this agreement, I agree to indemnify and hold them harmless in all such fees and costs.
4. I certify that I have adequate insurance to cover any injury or damage my child may incur or suffer while participating, or else I agree to bear the costs of such injury or damage myself.  I further certify that I am willing to assume the risk of any medical or physical condition I may have. 
5. In the event that I file a lawsuit against MTYR, I agree to do so solely in the State of Colorado, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state.  I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. 
6. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child’s participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against MTYR or the basis of any claim from which I have released them herein. 
7. I have had sufficient opportunity to read this entire document.  I have read and understand it and I agree to be bound by it’s terms. 

Signature_______________________________  Print name__________________________ Date___________

Address__________________________________________City______________________State_____ Zip________

Phone (_____) ______-___________

Relationship to child, circle one    Parent      Guardian   Other ____________

Mailing address:  7129 County Road 4 West, Del Norte, CO  81132 | 719 852-3870| Admin

Camp physical address: 41450 Forest Road # 250, also called 12 S, Monte Vista, CO  81144

emails:  butchr@amigo.net or blessedsch@gmail.com