Please circle all that apply  UCD | CCD | MSC | AHEC | FACULTY | STAFF | GUEST

OUTING:                                               OUTING NUMBER:____________

NAME:_________________________________________________________

ADDRESS:_____________________________________________________

_________________________________________________________________________

HOME PHONE:__________________WORK PHONE:__________________

SCHOOL ID___________________  EMAIL:__________________________

Please read and sign our liability disclaimer:
In consideration of my being permitted to participate in the above mentioned activity, I, the undersigned, hereby release and hold harmless Metropolitan State College of Denver and Campus Recreation at Auraria from all claims , losses, damage or expenses because of personal or bodily injury incurred or caused by me during or in conjunction with the above mentioned activity.  I further recognize that participation in such extracurricular activity is voluntary on my part and is not required or mandatory.  In filling out this form, I acknowledge that I fully understand the risk that is inherent to outdoor adventure activities.  Furthermore, I have read and fully understand my liability and do accept the restriction.

I understand that cancellation after the registration deadline will result in forfeiture of outing fee. Deadlines are on the Wednesday prior to the outing at 5:00 PM, unless otherwise specified.

Signature___________________________________Date________________20______

 

OA      REQUIRED HEALTH INFORMATION         OA
Please be thorough, this information may protect you in the event of an emergency.

Health insurance company_______________________________________

Health policy number___________________________________________

What is your: Age___________ Gender _____________          

Do you have allergies?         YES       NO               If so, Please list:

____________________________________________________________

____________________________________________________________

Please list any health conditions you feel we should be aware of:

____________________________________________________________

____________________________________________________________

Emergency Contact Information:

Name__________________________________________

Home phone _______________ Work ________________                         

Relationship_____________________________________

Address________________________________________

PHOTO RELEASE
Please read and initial_________________
I give my permission for The Metropolitan State College of Denver, Campus Recreation at Auraria to use my photograph/image in any official publication or presentation (including multimedia, i.e., The Metropolitan State College of Denver Web site). I also understand that I will not be compensated monetarily for my time or the use of my image.