2022 #49 Colorado August Expedition

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.If you have attended a past event, please use the same email to properly link your profile information.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
Height* This field is required.We require your height and weight information for the Jeep/UTV ride. The information helps place men in vehicles that would best suit them and that they would most enjoy.
7
Weight* This field is required.We require your height and weight information for the Jeep/UTV ride. The information helps place men in vehicles that would best suit them and that they would most enjoy.
8
Roommate RequestIf you would like to request to stay in a room with someone else on the trip, please specify their name here.
9
Emergency Contact Name* This field is required.
First Name
Last Name
10
Emergency Contact Relationship to Participant* This field is required.
11
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
12
Family Doctor Name* This field is required.
13
Family Doctor Phone Number* This field is required.
Area Code
Phone Number
14
Family Doctor Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Health Insurance Company Name* This field is required.
16
Health Insurance Policy Number* This field is required.
17
Health Insurance Phone Number* This field is required.
Area Code
Phone Number
18
Health Insurance Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
Known Allergies* This field is required.Specify any allergies/drugs you are allergic to
20
Electronic Signature Consent* This field is required.By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
Yes
21
Agree Not Psychotherapy* This field is required.I hereby voluntarily consent to participate in this event. I understand this event is educational and not psychotherapy or a substitute for psychotherapy.
Yes
22
Agree to COVID Risk* This field is required.By clicking submit below, you are acknowledging that an inherent risk of exposure to COVID-19 exists in any public place where people are present. By attending the Adventures of the Heart Expedition, you and any guests voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Iron Horse Ranch or Adventures of the Heart liable for any illness or injury.
Yes
23
Agree to Activities* This field is required.I understand that the event and its various parts involve mental, intellectual, emotional and physical activity, including, but not limited to: role playing, and exercises that may tax my intellectual, mental, and emotional capacity. I understand that the event and the optional free time activities of paintball, rock climbing, hiking and rappelling may pose a risk of physical or other injury to myself and others. I understand and acknowledge that my participation in the event and the optional free time activities and in every separate part thereof is purely voluntary and that at all times I will be free to choose NOT to participate in any part or all of the event. I acknowledge my responsibility for exercising my own judgment and initiative in choosing what parts of the event, if any, I will participate in. I acknowledge that my choices and actions pose a risk of physical or other injury to myself or others. By this consent I knowingly and voluntarily assume the risk of any physical or other injury either to myself or caused to others by me in the event. I hereby release Adventures of the Heart its officers, directors, employees, agents and staff from any and all liability for physical and other injuries to myself. I hereby agree to indemnify and hold harmless Adventures of the Heart, its officers, directors, employees, and staff from any and all liability for physical and other injuries to myself and for any injury to others caused by me.
Yes
24
Assumption of Risk* This field is required.I take responsibility for consulting with a medical doctor and/or psychotherapist prior to participating in the event concerning any known or potential physical, mental or emotional condition which I have or may have, for the purpose of getting medical and/or psychotherapeutic permission to participate. I assume the risk, by this consent, of any physical or other injury, illness or conditions during the event and hereby release Adventures of the Heart its officers, directors, employees, agents, and staff from any and all liability thereof.
Yes
25
Authorization to Help* This field is required.4) I hereby authorize Adventures of the Heart, its officers, directors, employees, agents and staff to take any and all reasonable steps on my behalf in the case of any physical or other injury, illness or condition I might suffer during the event. Adventures of the Heart, its officers, directors, employees, agents and staff may apply emergency first aid, engage physicians of any kind, nursing services, ambulance services, paramedic services, or any other service or personnel that in the sole discretion of Adventures of the Heart, its officers, directors, employees, agents or staff may be deemed reasonable or necessary. I hereby agree to indemnify and hold harmless Adventures of the Heart, its officers, directors, employees, agents and staff of and from any and all liability, claims, suits and damages, including, but without limitation, the cost, arising out of or with respect to the engagement of such services and/or personnel on my behalf. Further, I hereby knowingly and voluntarily release Adventures of the Heart, its officers, directors, employees, agents and staff of and from any liability for any physical or other injury that I may suffer as a result of Adventures of the Heart engagement of such services and/or personnel on my behalf.
Yes
26
SPRING CANYON RETREAT & CONFERENCE CENTER AGREEMENT FOR WAIVER, RELEASE, DISCHARGE, AND ASSUMPTION OF RISKS. This document affects your legal rights. You must read it and understand it before signing it.* This field is required.I, being over the age of eighteen, on behalf of myself, the person for whom I may be acting as legal guardian, my successors, heirs, assigns, personal representatives and estate, and any other person or entity who could claim under me or on my behalf, in consideration of the services provided by Spring Canyon Retreat & Conference Center (hereinafter cited as Spring Canyon), agree to assume the following risks and to waive, release and discharge Spring Canyon and its employees, managers, agents, owners, and other persons (hereinafter cited as SC personnel) as follows: DISCLOSURE OF RISKS , I am aware that snowmobiling, kayaking, ropes course, horseback riding, mountain biking, tubing, climbing & rappelling, use of All Terrain Vehicles (ATVs), trips into the backcountry, child care, and any other activities in which I am about to voluntarily engage bear known and unknown risks which could result in injury, death, illness, mental, or physical harm to myself and others, and/or damage to my property or to the property of others. These risks and hazards include but are not limited to: HYPOTHERMIA, COLD, HEAT, FREEZING, EXPOSURE, DROWNING, WINDBURN, SUNBURN, FROSTBITE, CHANGING WEATHER, EXISTING AND CHANGING SNOW, TRAIL AND WATER CONDITION, BARE SPOTS, ROCKS, STUMPS, TREES, AVALANCHES, COLLISIONS WITH NATURAL OBJECTS, MANMADE OBJECTS OR OTHER PERSONS OR THINGS, ROLL-OVERS, VARIATIONS IN TERRAIN, FAILURE OF OTHER PERSONS TO PARTICIPATE WITHIN THEIR OWN ABILITIES, POSSIBLE INJURY FROM CARRYING, TOWING, LIFTING AND DRAGGING OF EQUIPMENT, FAILURES OF EQUIPMENT, MY OWN PHYSICAL CONDITION, THE CONSUMPTION OF FOOD OR DRINK, AND THE BEHAVIOR OF WILD OR DOMESTICATED ANIMALS. ASSUMPTION OF RISK. I voluntarily assume and accept the risks of any such injury or harm to my person or property which may result from the hazards described above or any other hazards related to any activity in which I may participate or engage with Spring Canyon. This assumption of risk includes the risk of injury or harm which may be caused by acts of omission or negligence by Spring Canyon or any SC personnel. WAIVE, RELEASE AND DISCHARGE. I voluntarily waive, release and discharge Spring Canyon and SC personnel from any and all liability, claims, demands, or causes of action which are in any way, directly or indirectly, related to, arise from, or are in any way connected with my participation in any Spring Canyon activity, to include claims related to the hazards described above, as well as the negligent acts or omissions of all SC personnel. I agree to follow the instructions of Spring Canyon team leaders or instructors to wear a helmet at all times, and to obey all posted signs and all other written or verbal instructions. I agree to hold harmless and indemnify Spring Canyon and SC personnel from all costs and attorney’s fees in connection with any claim or claims which may arise as a result of any activity in which I engage with Spring Canyon. INSURANCE AND PHYSICAL CONDITION. I understand no medical or other insurance benefits are being provided to me during or after my participation in any Spring Canyon activity. I certify that I am in good health and that I have no physical condition, mental condition, disability, impairment, or injury which would make it difficult or dangerous for me to participate in any of Spring Canyon’s activity. I understand that Spring Canyon is relying on my statement of good health and condition in allowing me to participate in any activity. MENTAL CAPACITY. I further state that I am not under the influence of alcohol or any other legal or illegal substances, nor will I be under the influence of alcohol or any other legal or illegal substance, which would impair my current ability to safely operate a snowmobile or ATV or engage in any other Spring Canyon activities, or which would impair my ability to knowingly and voluntarily enter into this agreement. COVID-19. On behalf of myself and my children, I hereby release, covenant not to sue, discharge, and hold harmless Spring Canyon, its employees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to my participation in programs, services or activities. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of this organization, its employees, agents, owners, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any such program, service or activity. EFFECT OF RELEASE AND ENTIRE AGREEMENT. I understand and agree that, by signing this agreement, I am forever releasing and waiving any legal right I may have to attempt to recover damages, attorney’s fees, costs or other amounts through a lawsuit or otherwise, from Spring Canyon or SC personnel, for any injury or harm to myself or others resulting from any of the dangers, risks, or actions described above or any other activities in which I may engage with Spring Canyon. I understand the meaning of this document and that this is the entire agreement between myself and Spring Canyon and SC personnel. I HAVE READ THIS ENTIRE AGREEMENT, UNDERSTAND IT, AND AGREE TO BE BOUND BY ITS TERMS.
Yes
27
Assumption of Risk / Liability Release* This field is required.By entering my name below, I am aware in signing this document for participation in this program that certain elements of the activity are physically and emotionally demanding. Furthermore, I understand that certain risks and dangers exist in the activities in which I am participating.
First Name
Last Name
28
Get Page URL
Should be Empty: