Health Insurance Proof of Coverage Form HiddenDisplay Fields UG Orientation ODAL Summer dynamic population parameter = display_fieldsChoose Your SNO Camp* River Camp Mountain Camp HiddenTrip Key Hidden Use this field to flag submissions using a query string. Parameter = trip_key. Usage: a href="formURL?trip_key=sometrip" or [gravityform id=88 field_values='trip_key=sometrip']Name* First Last Phone*Email* Student ID Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Emergency Contact InformationName* First Last Contact is* Parent Guardian Phone*Insurance InformationProvider* Group ID / Policy #* Provider Phone*Medical InformationDo you have any allergies?*Do you suffer from any significant medical conditions?*Are you taking any medications (prescription or non-prescription)? If so, for what conditions and at what dosages?*Do you currently have any significant injuries?*List any past injuries that we should know about*I have a medical condition that would prevent my participation in student activities* Yes No Conditions*NOTE: By signing this Participant Agreement, you are releasing Sierra Nevada University, its affiliates, officers, trustees, faculty, staff, coaches, agents, employees, hired guides, sponsors, and the hosting site on whose premises Activities occur (collectively “SNU”), from and against any and all liability, including liability for negligence, and you are acknowledging that SNU is disclaiming all warranties. This Participant Agreement is applicable to all SNU sponsored activities, travel, and athletic events, whether on or off campus Activities. I understand that all rules outlined in the SNU Student Handbook (the “Handbook”) apply to all Activities, whether I am a student, parent, staff member, community member, or other participant. I agree to abide by the Handbook and any special conditions set forth for each Activity I participate in, including, but not limited to, curfew, group assignments, and security of individual and group belongings. In the event that any SNU personnel deem my behavior unruly or insubordinate or I am found in violation of the Handbook or any specific Activity’s rules, I may be sent back to SNU or dismissed from the Activity. Any decision to dismiss me from participation in an Activity by the Activity’s leaders is final. If dismissed from an off-campus Activity, I understand that I will be personally responsible for my return travel expenses and will be charged by SNU for any expenses incurred. I acknowledge that the rules and policies of SNU are stated in the Handbook. I understand that I am responsible for reading the Handbook and abiding by all rules and policies stated there in. The Handbook is available online at: www.sierranevada.edu/resources/current-undergraduate-students/ Except as otherwise provided herein or in the Handbook, as a participant, I understand that the use of alcohol, illegal drugs, and certain prescription drugs are prohibited for the duration of all Activities. Failure to abide by SNU’s alcohol and drug policy will result in dismissal from the Activity without refund and possible loss of course credit, if applicable. I understand that I will become personally responsible for my return travel expenses. In limited circumstances, SNU approval of Activities may include authorization for consumption of alcohol. When authorized in accordance with SNU policies, participants of legal drinking age may consume alcohol at approved Activities. All participants must act responsibly and with restraint in these instances. I understand that Activities may include participation in rigorous activities, which may involve a risk of damage or loss to my personal belongings. I understand that I am fully responsible for my personal belongings and will not hold SNU or the Activity leaders liable for any expenses due to loss and/or damage to my personal belongings. I understand that if I do not own the equipment needed to participate in an Activity, I may have the option to rent equipment from SNU and will be personally responsible for its condition and whereabouts during the contracted time in my custody. I understand that I will be charged late fees, repair fees, and/or replacement fees of the equipment if it is lost, damaged, or stolen during the contracted time it is issued to me, or if I fail to return it by the contracted return date. I expressly disclaim any and all warranties connected with any equipment rented from SNU, and agree that I have inspected and agree to accept all rented equipment “AS IS” and agree that there are no warranties with respect to such equipment which extend beyond the face of this Participant Agreement. I certify now and again immediately before each Activity that I have no past or current physical or psychological condition that might affect my participation in an Activity, other than as described on the Medical History form. I am able to participate without causing harm to myself, or to others. The medical information given to SNU is accurate and all pertinent medical conditions have been disclosed. I agree to promptly update my medical history as circumstances and my condition change. I understand that SNU’s admission of me to an Activity is not intended as a representation that SNU Activity leaders will be able to manage successfully a medical event or emergency related to a disclosed, or undisclosed, medical condition. The responsibility for determining a participant’s suitability for an Activity is not SNU’s but, rather, the participant’s, guided by family and her or his physician. SNU reserves the right to refuse admission or remove a participant from any Activity for any reason it deems in the best interests of the participant, other participants, or SNU. SNU is authorized to obtain or provide emergency hospitalization, surgical or other medical care for me. I understand that situations may arise in which third-party medical care is not available and which require SNU staff and faculty to provide first aid and possibly more advanced procedures, employing wilderness first responder training. Any third-party medical care provider is authorized to exchange pertinent medical information with SNU. Costs reasonably associated with medical services, including evacuation, shall be borne by me. As a participant, I acknowledge that SNU may share my contact information with other SNU students or graduates and/or with environmental organizations or strategic partners in which SNU graduates may be interested; and SNU may use my name, contact information and photo or other image in promotional materials and press releases. Activities and Assumption of Risk I understand that participation in Activities may be dangerous and may expose me to risk of serious bodily injury, including but not limited to: serious burns; falls; bites; broken bones; dislocations; contusions; sprains; concussions; frostbite; hypothermia; sunburn; cardiac arrest; exhaustion; dehydration; spinal cord and brain injury that may result in paralysis and the possibility of other permanent injury; and possibly death. These risks include, but are not limited to: the possibility of collisions with other participants, spectators and the public; equipment failure; cooking over gas stoves; sleeping in cold weather; weather changes (heavy rain, lightning, snowstorms); rock fall, drinking untreated water; traveling over challenging terrain with equipment; avalanches; physical exertion at high altitude; drowning; poison oak allergies; vehicle accidents while traveling to and from Activities; traveling to and within, and returning from, one or more foreign countries; foreign political, legal, social, and economic conditions; different standards of design, safety, and maintenance of buildings, public places and conveniences; and local medical and weather conditions. I understand that no degree of care or caution can completely eliminate these risks. I hereby freely and expressly assume and accept any and all risk of illness, injury and/or death arising from my participation in any and all Activities I may undertake, or while traveling to and from Activities, or from the use of any equipment provided or furnished to me by SNU. As a participant in each Activity, I take full responsibility and agree not to hold SNU or the Activity leaders, in the normal execution of their duties, liable for any illness, accident or injury that could ensue, or be related to participation on an Activity. I understand that some Activities require participants to live, camp and travel out of doors. Activities vary from event to event and include, among others, competitive sports, hiking and backpacking through mountainous and other terrain, mountaineering and climbing on rock cliffs, steep snow, whitewater kayaking, whitewater rafting, paddleboarding, sea kayaking, skiing, snowboarding, mountain biking and canyoneering. I further understand and acknowledge that the Activities have risks, including certain risks which are inherent. Inherent risks are those that cannot be eliminated without destroying the unique character of the Activities. The same elements that contribute to the unique character of these Activities can cause loss or damage to equipment, accidental injury, illness, or, in extreme cases, permanent trauma, disability or death. I understand that participation in some Activities may require participants to live, camp, travel, participate, and work together in close physical proximity, where social distancing practices may be impractical. Participating in Activities in close proximity to others may expose participants to viruses, bacteria, infections, and other illnesses, including without limitations, COVID-19, upper respiratory viruses, influenza, and other communicable diseases. Participants are responsible for evaluating their own vulnerability to such illnesses and making their own independent decision to participate in Activities and assume all risks related to contracting or spreading such illnesses. Participants are encouraged to take precautions, including use of personal protective equipment, regular and thorough handwashing, and other measures to reduce the risk of contracting and the spread of illnesses. The following describes some, but not all, of the inherent risks of Activities: • Activities may be strenuous, physically and emotionally. • Activities often occur in remote places. They occur on lands open to the public, and exposed to the acts of persons not associated with SNU. The remote locations may be many hours from medical facilities. Communication and transportation are difficult and evacuations and medical care may be significantly delayed. • Equipment may fail or malfunction. • Meals are prepared over gas stoves and open fires. Water may require disinfection before use. Participants with food allergies or sensitivities may come in contact with offending food types. Camping risks include burns and cuts, sprains, strains and other injuries from slips, falls, and lifting, and illnesses including diarrhea and flu-like illness. • Travel may be by SNU vehicle, participant carpool, bike, raft, kayak, skis, snowboards, snowshoes, on foot and by other means, over improved and unimproved roads, rugged trails and off-trail terrain, including boulder fields, downed timber, rivers, rapids, river crossings, high mountain passes, snow and ice, steep slopes, slippery rocks, ocean tides, currents, waves, and surf. Travel risks include collision, falling, capsizing, drowning, becoming lost, and other risks usually associated with such travel, including environmental risks. • Environmental risks and hazards include flowing, deep and/or cold water; insects, snakes, predators, and large animals; falling and rolling rock; lightning, avalanches, flash floods, falling timber and forces of nature, including weather which may change to extreme conditions. Possible injuries and illnesses include hypothermia, frostbite, immersion foot, high altitude illnesses, sunburn, heatstroke, dehydration, and other mild or serious conditions. • Decisions made by Activity leaders and Activity participants will be based on a variety of perceptions and evaluations, which by their nature are imprecise and subject to errors in judgment. Misjudgments may pertain to, among other things, a participant’s capabilities, environment, terrain, water and weather conditions, natural hazards, routes and medical conditions. • Activities in foreign countries may encounter different laws, legal systems, social customs and behaviors; political and economic conditions; standards of design, safety, and maintenance of buildings, public places and conveniences; local medical and weather conditions; and exposure to animals, diseases and infections; that are not common to the United States. In addition, these Activities may be subject to dangerous road travel, political unrest, riots, demonstrations, banditry, terrorism and other criminal conduct, including drug related activities. SNU practices in foreign countries are generally consistent with customs and standards used in the United States regarding such practices. • SNU may from time to time use the services of private contractors for certain tasks, including, for example, transportation. SNU is not responsible for the acts or omissions of such contractors. I understand that SNU does not provide transportation to and from all Activities. In such cases, I accept full responsibility for providing my own transportation, including associated costs. SNU is not responsible for any bodily injury or property damage that may arise out of my transportation arrangements, and I agree to defend, indemnify, and hold SNU harmless from any bodily injury, property damage, or other incident which may arise out of my transportation arrangements or any personal time or activities that occur outside the authorized Activities scheduled as part of an SNU Activity. Agreement of Release and Indemnity I have carefully read the Terms and Conditions of this Participant Agreement and fully understand its contents. I am aware that this is a release of important legal rights and a disclaimer of important warranties, that I AM SIGNING THIS PARTICIPANT AGREEMENT IN CONSIDERATION OF MY PARTICIPATION IN ACTIVITIES, AND THAT THIS PARTICIPANT AGREEMENT IS A LEGALLY BINDING AGREEMENT BETWEEN MYSELF AND SNU, WHICH I SIGN FREELY AND VOLUNTARILY. I hereby release SNU from liability for any and all illnesses, injuries, and damages, including hospitalization and death, arising from my participation in any and all Activities I may undertake, including the use of any and all equipment provided or furnished to me. In so doing, I release SNU from all liability, including, but not limited to, liability for negligence, failure to warn, product liability and warranty arising out of or in any way connected with my participation in Activities. I understand that SNU is not responsible for testing or screening participants for any illness as a condition to participating in any Activity, and I release SNU from any such obligation. Furthermore, I promise and agree not to make any claim or commence any lawsuit against SNU for illness, injuries, or damages arising from my participation in Activities or from the use of such equipment. I expressly acknowledge and agree that Activities can be dangerous and involve serious and unpredictable risks of illness, bodily injury, property damage, and death and that I intend the foregoing waiver and release of SNU to be as broad and inclusive as permitted by law. I further expressly agree to indemnify and hold harmless SNU against loss from any further claims, demands or actions that may subsequently be brought by me or by any other persons on account of damages, injury , or illness of any character resulting to me or any other person or property arising from my participation in any Activities, or the use of any equipment provided or furnished to me. I promise and agree that I will not allow any other person to use any equipment provided or furnished to me by SNU, without SNU consent. Other Provisions I further agree, as a participant in Activities, as follows: Any dispute between me and SNU will be governed by the substantive laws (not including the laws which might apply the laws of another jurisdiction) of the State of Nevada, and any mediation or suit shall occur or be filed only in the State of Nevada. If any part of this agreement is found by a court or other appropriate authority to be invalid, the remainder of the agreement nevertheless will be in full force and effect. THE PARTICIPANT HAS READ THIS DOCUMENT AND UNDERSTANDS AND VOLUNTARILY AGREES TO ITS TERMS, WHICH SHALL BE BINDING UPON THEM, THEIR HEIRS, ESTATE, EXECUTORS AND ADMINISTRATORS. I have read and agree to all conditions aboveSignature*Signature of Parent or GuardianRequired if participant is under 18 years of agePaymentMountain Expedition Camp* Price: Option* June 26-June 30, 2021 August 2-August 6, 2021 Total $0.00 Billing Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name Δ