Please type or print all information: This form is required for all participants attending events. This form must be completed by the parent, legal guardian, or person in loco parentis for the youth participant.




         Last name                   First name                                 Middle Initial


 Mailing Address       Street Address                                                                                                          



 City            State/Province              Postal Code                             Country


 Sex (circle one)      F     M     Height                          Weight                    


 Birth Date   Month:                      Day:                         Year:                      


 E-mail Address                                                                                                     


 School Name: _______________________________________________________


Low Ropes Initiatives/Activities:  I hereby affirm that I have been well advised and thoroughly informed of the inherent hazards and policies of participating in initiatives/activities, including low ropes.  I know that I am participating in a potentially hazardous activity.  I should not participate unless I am medically able.  I hereby personally assume all risks associated with my voluntary participation in this event for any harm, injury or damage that may befall me as a result of my participation, whether foreseen or unforeseen.  I must recognize the importance of following the leader’s instructions, and know that safety rules and procedures must be obeyed.  I know that participation is by choice, and have been advised of the dangers and risks.  

Travel:  Parents/Guardians of Key Leader participants are responsible for the transportation to/ from the event.  It is recommended that the guidelines from the student’s school/sponsoring organization should be followed.  KI is not responsible for transportation, and shall be held harmless for any liability arising from transportation to and from a Key Leader e vent.  

Participant Signature                                                              

Parent/Legal Guardian   ________________                        


 Emergency Information

 In case of emergency, contact:                                                                      Relationship to participant:                                                      

 Daytime phone                                                                                                                                               Evening/cell phone                                                                             


Alternate contact                                                                                               Relationship to participant                                                       


 Daytime phone                                                                                                  Evening/cell phone                                                                  


Medical Information


Health Insurance Company                                                                                                     Policy Number                                                                                                                     


 Group Name on Insurance Coverage                                                                                                                                                                                                                                 


Telephone number or other contact information shown on insurance card                                                                                                                                                                                                                                    


 Will the Key Leader participant be taking any prescription medication or over-the-counter drugs of any type?                                                                                                                                                                                                                                    


If yes, please explain                                                                                                                                                                                             


 Has he/she ever been or currently being treated for (circle “Yes” or “No”)?

 Nervousness?                     Yes   No               Rheumatic Fever?                Yes   No                Asthma?                                Yes   No

 Convulsion or epilepsy?     Yes   No               Cancer or tumors?                Yes   No                Diabetes?                              Yes   No

 Heart Condition?                Yes   No                Headaches?                          Yes   No              Allergies to medication?        Yes   No

 High Blood Pressure?        Yes   No               Fainting Spells?                     Yes   No 

 List any allergies or other medical conditions of which we need to be aware                                                                                                                                                                                                                              


 For routine first aid needs, list any O-T-C medications that the Key Leader Participant may NOT take                                                                                                                                                                                                                                  


 I am the parent or legal guardian for the above-named Key Leader participant, and give my permission for him/her to attend the weekend retreat,  sponsored by Kiwanis International.  I also have read and understand the Community Values Agreement, and I understand that a violation of certain  provisions of these rules may result in the dismissal of my Key Leader participant from the event. I hereby certify that the information provided above is



 In the case of medical emergency, I understand that every effort will be made to contact the emergency contacts listed above.  In the event those persons  cannot be reached or time does not permit, I hereby give permission to a licensed physician or other licensed medical provider, to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery, for the above-named Key Leader participant.  On behalf of

 myself and my ward/minor, I/we hereby RELEASE, WAIVE AND FOREVER DISCHARGE Kiwanis International and its officers, directors, employees,  parents and subsidiaries, agents, from any and all claims, liabilities, causes of actions, damages, demands, judgments, executions, liens and costs  whatsoever, in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (i)  claims made against medical providers of emergency services under this authorization, or (ii) against Kiwanis International for obtaining medical

emergency services for said Key Leader participant pursuant to this authorization.



 Parent or guardian                                                              Signature                                                                               Date                        

(Required if under the age of 18)