Adaptive Fishing Registration Form

Adaptive Fishing Registration

Fishing will be held near Jemez Springs in October. For the safety of participants, the dates, times and full address of the locations will be sent directly to participants following registration. Filling out this form will add you to a text/email list for this specific program. As a reminder, a guardian is required to stay at all programs to be able to provide individual support/supervision for their participant(s).
Participant Information
Participant's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Gender*
Has the participant been seen at Carrie Tingley Hospital within the past 2 years?*
Qualifying Diagnosis*
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the participant ever participated in Adaptive Sports previously?*

Guardian Information
Guardian Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Annual Household Income*
Number of Household Members*
Emergency Contact

In the event of an emergency or other urgent situation, every attempt will be made to contact the Guardian listed above. If they cannot be reached, the Emergency Contact listed below will be the next person reached out to.
Emergency Contact Name*

First NameLast Name
Relationship to Participant*
Emergency Contact Phone Number*
Please enter a valid phone number.
Does the emergency contact have permission to pick up the participant from a program if needed?*

YesNo

Consent Forms
Medical Release and Authorization

As the parent and/or legal guardian of the named participant, I hereby authorize the staff and volunteers of the Carrie Tingley Hospital Foundation to provide basic medical care, such as first aid or CPR, if the need arises during participation in this program. I understand that staff and volunteers will only administer care for which they have received proper training and certification from a recognized accrediting body for.

If the participant requires medical treatment beyond basic care, they may only be transported by a legal guardian, an emergency contact, or professional emergency services (e.g., ambulance, life-flight). I acknowledge that staff and volunteers of the Carrie Tingley Hospital Foundation will not transport the participant to an urgent care center, emergency room, or any other medical facility.

In the event that emergency medical care is necessary, every reasonable effort will be made to contact the parent/guardian listed on this form. If no response is received, the emergency contact will be notified. If neither the guardian nor the emergency contact can be reached, I understand that the Carrie Tingley Hospital Foundation may contact professional emergency services to transport the participant to another facility for medical evaluation and treatment.

I acknowledge that all medical expenses incurred as a result of illness or injury during the participation in this program are the sole financial responsibility of the participants parent/guardian and/or their health insurance provider. I release and hold harmless the Carrie Tingley Hospital Foundation, its staff, volunteers, and affiliates from any claims, liabilities, or expenses arising from medical care provided in good faith under this authorization.
Informed Consent

I, the undersigned parent and/or legal guardian, hereby give my consent for the named individual to participate in all activities organized by the Carrie Tingley Hospital Foundation during the selected program. In consideration of the individuals' participation, I voluntarily assume all risks and hazards associated with these activities, including but not limited to those occurring during travel to and from program sessions.

I hereby release, indemnify, and hold harmless the Carrie Tingley Hospital Foundation, its officers, agents, representatives, volunteers, and any affiliated entities from any and all liability for injuries, damages, or losses incurred by the individual as a result of participation in program activities.

I acknowledge and understand that participation in physical activities, including adaptive sports such as adaptive fishing, carries inherent risks. These risks may include, but are not limited to, sprains, fractures, paralysis, or other serious injuries, including death. I further waive any claims against the Carrie Tingley Hospital Foundation, its staff, volunteers, sponsors, advertisers, and, if applicable, property owners or lessors of program venues.

Photo/Video Waiver

In consideration of the individuals' participation at this event, I hereby grant permission to Carrie Tingley Hospital Foundation's staff and affiliates to utilize the participants' appearance, performance and/or voice in published media for the purpose of promotion, reporting or publication related to the organization. I understand that no royalty, fee or any other compensation of any kind shall become payable to me for the organizations use of the child's appearance, likeness, voice, etc. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.
Confirmation

By signing and dating below, I confirm that the information provided on this form is true and accurate to the best of my knowledge. By signing and dating below, I agree to abide by the waivers and releases listed above. I acknowledge that by submitting my electronic signature, it carries the same legal effect as a handwritten signature and is equally binding.
Signature*

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Date Signed*

MonthDayYear
Date
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Adaptive Fishing Registration

Participant Information

Guardian Information

Emergency Contact

Consent Forms

Confirmation