PARTICIPANT CONSENT, RELEASE AND ASSUMPTION OF RISK
CAMPTOWN adventure programs involve a variety of activities. Some programs may include rigorous physical activities such as backpacking, paddling, climbing, biking, whitewater rafting, swimming or hiking. These activities are designed to be within the physical, mental and emotional limits of a person in reasonably good health. The level of participation in all programs and activities is at all times completely up to the individual. I acknowledge that my participation in backpacking, paddling, climbing, biking, whitewater rafting, swimming, hiking and/or individual and group activities of any kind entail known and unanticipated risks that could result in physical or emotional injury or death. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I expressly accept and assume all of the risks existing in any activity. My participation in any activity is voluntary, and I state that I elect or will elect to participate in spite of the risk. In consideration for being allowed to participate in CAMPTOWN activities and trips, being fully aware of the nature of the risks and hazards of participation in CAMPTOWN activities including but not limited to the possibility of physical or emotional injury, death, or loss of or damage to personal property, I do knowingly and willingly release and hold harmless CAMPTOWN, INC. and its officers, agents, sponsors, volunteers, and employees and all persons associated in any way with CAMPTOWN, INC. from any claims, causes of action or liability for property damage and/or physical injury or death in connection with or during any CAMPTOWN activity. This release is made on behalf of myself and/or my minor child and my/his/her heirs, representatives, executors, administrators and assigns. I further consent to the use of any photographs (motion or still) or any records of my likeness, or that of my minor child, which may be taken or made by CAMPTOWN representatives with the understanding that such photographs or recordings are for CAMPTOWN publicity or promotional purposes only and not for commercial distribution. By signing this document, I agree that if I or my minor child is hurt or property is damaged during participation in CAMPTOWN activities, I waive my right to bring or maintain a lawsuit or claim against CAMPTOWN. I also acknowledge that I have fully satisfied myself as to the nature of the activity or activities in which I or my minor child will be participating, the risks associated with each such activity and my responsibility to know my or my minor child’s limits. I assume all these risks. In the event of illness or injury, I hereby give my consent to provide emergency medical care including hospitalization, anesthesia, surgery, injections of medication or other treatment that may become necessary.
I have had sufficient opportunity to read this entire document. I have read and understand it, and I agree to be bound by its terms.
Signature of Participant ____________________________
Print Name ______________________________________________
PARENT’S OR GUARDIAN’S ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18)
I certify that I am the parent/legal guardian for _____________________________ (print minor’s name) who desires to participate in CAMPTOWN, INC activities. I affirm, under penalties for perjury, that I am my minor child’s parent or legal guardian and I consent to my child’s participation with CAMPTOWN. activities and that I have read the above and understand its meaning. Signature of Parent/Guardian ________________________ Print Name _____________________________________ Address ________________________________________
Emergency Contact Information If above not available in an emergency, contact: Name________________________________________ Relationship ________________ Home Phone ___________________ Work Number __________________ Cell Number ___________________ HEALTH QUESTIONAIRE
Participant Name: ____________________________
The information requested on this form is intended to help alert staff to pre-existing medical conditions. This information will be held in confidence. WE STRONGLY RECOMMEND THAT YOU CONSULT YOUR PHYSICIAN IF YOU HAVE ANY PRE- EXISTING CONDITIONS BEFORE PARTICIPATION IN A CAMPTOWN ADVENTURE. GENERAL & MEDICAL INFORMATION Health Insurance Company Name ____________________________________ Phone Number ____________________________ Policy Holder Name ______________________________________________ Policy or ID # _____________________________ Do you have any limiting physical or health disabilities, temporary or permanent, that you or your
Doctor feel would limit your participation in a CAMPTOWN activity?
If yes, please explain _______________________________________________________________________________
If yes, please explain ___________________________________________________________________________________
Do you have or have you had a history of: (please check all that apply) __ Asthma
__ Other ______________________________________
Please explain health problem checked above: PROBLEM WHAT WE WILL SEE TREATMENT LIMITATIONS
People are threatened each day by acute reactions to insect stings and unknown food allergies. CAMPTOWN participants that have an identified allergy need to provide medication to have available for immediate use. CAMPTOWN is also concerned about those participants that have not been identified with a known allergy. CAMPTOWN has taken steps to have a local physician write an order for an EPI-PEN. EPI-PEN contains adrenaline and is used only when a participant has an acute, life threatening reaction to a sting or food. I give the CAMPTOWN staff permission to administer the EPI-PEN in an emergency situation.
I HEREBY AUTHORIZE THAT THE INFORMATION PROVIDED WITHIN THIS HEALTH FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. Participant/Guardian Signature: __________________________________________________
(complete if participant is a minor) I give my permission to the staff of CAMPTOWN to administer the following medications to my child. Medications will be given according to the directions on the bottle. Over the counter dosages will be determined by the age and size of the child unless otherwise indicated by parent/guardian. Acetaminophen (Tylenol)
Signature of Parent/Guardian_________________________________
IDENTIFICATION OF THE SUBSTANCE / PREPARATION AND COMPANY OR Identification of the substance or preparation COMPOSITION / INFORMATION ON INGREDIENTS (Classification according to Directive 67/548/EEC) (Classification according to Directive 67/548/EEC) Information to exposure limit values - see section 8. PERMETHRIN SMOKE GENERATOR Safety Data Sheet Harmful if swallowed. Irritating to eye