Hearts on the Mountain Registration
April 6, 2013
at Eldora Mountain Resort
Space is limited to the first 25 Teens!
Registration starts March 1, 2013
This program is open to any foster, adoptive or kinship teen ages 10-18. Biological teens are welcomed as
well if accompanying a foster, adoptive or kinship sibling. We will provide transportation to and from
Eldora Mountain. Our pick up location will be at Hearts of the Rockies Christian Church (6501 Brittany
Street, Fort Collins 80525). Registration fee includes boots, ski & pole rentals or snowboard rentals; lift
ticket; lessons and lunch. We will have a volunteer to child ratio of 1:2. All volunteers will be screened and
trained by Kids at Heart.
Guardian 1 Name: ___________________________________ Phone: ________________________________
Email Address: _____________________________________________________________________________
Guardian 2 Name: ___________________________________ Phone: ________________________________
Email Address: _____________________________________________________________________________
Home Address: _____________________________________________________________________________
City: ____________________________ State: _______ Zip: __________ County: _______________________
Please list all the Teens who will participate:
#
Full Name*
Status**
(A, F, K, B)
Age
Ethnicity
Ski or
Board?
Boot Size
Ski /
Boarding
Level***
(B,I,A)
*If your child would like to be called by another name, please indicate that as well.
**B – Biological child; A- Adopted Child; F-Foster Child; K-Kinship care
*** B – beginner; I – intermediate; A – advanced (with regards to your child’s ability to ski / board)
Emergency Information: (Other than listed Guardians)
Emergency Contact________________________________________ Phone__________________________
Relationship to Guardian____________________________________________________________________
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Doctor’s Name___________________________________________ Phone___________________________
Health Insurance Company___________________________________________________________
Please initial all sections below:
______Statement of Health: All participants should be able to participate in physical activities at 9,400 feet. Basic First Aid will be
available during the event with more extensive care being provided by Eldora Mountain Resort.
______Functions and Activities - It is my understanding that participating in the programs, recreation and other activities of Heart of
the Rockies Christian Church at Eldora Mountain Resort is a privilege. Prior to my participation in such activities, I acknowledge
that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related
accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be
other risks inherent in these activities of which I may not be presently aware.
_______Release of Liability - By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of
withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or
me participating in the activities, whether such risks are known or unknown to me at this time. I further release Heart of the Rockies
Christian Church and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have or that I may
have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability
shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all
claims that members of the child's or my family or estate, heirs, representatives, or assigns may have against Heart of the Rockies
Christian Church or its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless the
church and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its
activities and programs, or as a result of injury or illness of my child during such activities.
________First Aid and Emergency Medical Treatment - I recognize that there may be occasions where the child named above or I,
if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health
condition or injury. I do hereby give permission for agents of Heart of the Rockies Christian Church to seek and secure any needed
medical attention or treatment for the child named above or me, if I am a participant, including hospitalization, if in the agent's opinion
such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission
for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I
agree to pay for the medical treatment.
________I represent that I am the parent/guardian of the children named above, who are under 18 years of age. I have read the above
Permission/Waiver Form and am fully familiar with the contents thereof.
________I give permission for the child named above to participate in the activities of Heart of the Rockies Christian Church,
including any special events/activities described above. In consideration for allowing the participation of the child in the activities of
the church, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of all listed children,
and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.
________________________________________________
Signature of Legal Guardian
_________________________
Date
PAYMENT INFORMATION & REGISTRATION PROCESS:
Registration fee is $30 per participant. Registration is limited to 25 participants and is based on a first come
first serve basis. You will be considered “registered” when the office has received and processed ALL of your
completed registration forms and fees. Each registration must be accompanied by the registration fee to
guarantee your space for the event. You may cancel and receive a full refund any time before March 22, 2013.
If a cancellation is received after March 22, 2013, the fees will not be refunded. When forms and fees are
received and processed by Kids at Heart, we will send you an e-mail letting you know that you are registered
(could take up to a week or two). At that time, we will also e-mail you directions, maps, packing list and other
relevant information. Send Registration & Fees to Kids at Heart 6501 Brittany Street
Fort Collins, CO 80525
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