2020 Gaff•N•Go Participant Forms

PARTICIPANTS AND JUDGES:
These forms are required in order to participate in the 2020 Gaff-N-Go Rodeo.
Once these forms are completed, click the submit button and they will be added to your registration.

Electronic Participant Forms

If you are human, leave this field blank.

2020 GAFF-n-GO LINEWORKER’S RODEO PARTICIPANT’S EMERGENCY MEDICAL FORM AND RELEASE INFORMATION

Please fill out this form completely and submit. All forms need to be completed and received by May 1, 2020.

Employer:

Coordinator Name:

Print Name: *

Date of Birth *

INSTRUCTIONS: Please complete one form for each participant in the 2020 Gaff-n-Go Lineworker’s Rodeo (hereinafter “Lineworker’s Rodeo”), whether the participant is a lineworker (apprentice or journeyman), an equipment operator, OR a judge. THIS FORM IS REQUIRED FOR ANYONE WHO IS TAKING PART IN LINEWORKER'S RODEO ACTIVITIES AS A PARTICIPANT. SHOULD A PARTICIPANT BE INJURED OR OTHERWISE REQUIRE EMERGENCY MEDICAL ATTENTION, EMERGENCY MEDICAL PERSONNEL NEED YOUR BASIC MEDICAL INFORMATION. We ask that you also provide contact information for someone who can make health care decisions on your behalf in an emergency (or who knows your wishes or the contents of an applicable advance directive). Please complete each section OR check the relevant box. This form will be used only for purposes related to the Lineworker’s Rodeo or in the event of an emergency. Assuming it is not needed, this form will be destroyed no later than three months after the Lineworker’s Rodeo has concluded.

RELEASES & MEDICAL AUTHORIZATION: Your employer, may, optionally, ask you to sign an additional release form prior to the Lineworker’s Rodeo on its own behalf. This may be done in advance. The “Association Release & Indemnification Agreement,” a copy of which is enclosed with the registration materials for you to read and review. As part of this REQUIRED “Association Release,” you authorize emergency medical treatment on your behalf, should you be unable to consent to such treatment, to be instituted without delay as the judgment of onsite medical personnel may dictate.

MEDICAL INFORMATION:

Check here if NONE to report

Please provide any basic medical history information that might be useful in a medical emergency, including (without limitation) any information about chronic conditions, such as asthma, diabetes, hypertension, or cardiac conditions.

LIMITATIONS:

Check here if NO LIMITS on treatment

Please list any limitations on emergency medical treatment, such as religious restrictions on receiving blood or blood products.

CURRENT DRUGS:

Check here if NOT CURRENTLY TAKING any medications

Current medications you are taking, and why? PLEASE LIST HERE AND BRING WITH YOU TO THE LINEWORKER'S RODEO ANY EMERGENCY MEDICATIONS, SUCH AS AN ASTHMA INHALER OR AN EPIPEN FOR ALLERGIC REACTIONS.

ALLERGIES:

Check here if NONE to report

Any drug, food, plant, or insect bite allergies?

EMERGENCY CONTACTS:

Emergency Contact Name: *

Relationship: *

Home Phone: *

Work Phone:

Cell Phone:

Second Emergency Name:

Relationship:

Home Phone:

Work Phone:

Cell Phone:

By my signature, I intend to adopt, and do adopt, the signature or typed name below or adjacent as my electronic signature, and, pursuant to the terms of the Virginia Uniform Electronic Transactions Act, intend to sign, and do in fact sign, this record, as of the date hereof. I further agree to conduct this transaction by electronic means.

Signature: *

Clear

(use your mouse to sign or click on the keyboard to type name.)

Date *

2020 Gaff•N•Go Participant Forms

2020 GAFF-n-GO LINEWORKER’S RODEO PARTICIPANT’S EMERGENCY MEDICAL FORM AND RELEASE INFORMATION

2020 Rodeo Sponsors

2020 Gaff-n-Go Lineworker's Rodeo - CONTACT US