Form #1
Northland Pines Ropes and Challenge Course
Assumption of Risk and Registration Form
Forms 1,2, and 3 must be signed by all participants
I am aware in signing this document for participation in the Ropes and Challenge Course (RCC) experience, that certain elements of the program can be physically and emotionally demanding. I understand that although the professional staff will make every reasonable effort to minimize exposure to known risks, not all dangers and hazards can abe foreseen (ie: cuts, scrapes, bruises, fractures, debilitating injuries, fatalities, etc.). Furthermore, I am aware that certain risks and dangers exist in these activities that are beyond the control of the sponsoring agency and its’ staff. I understand that NPRCC has the right to deny participation and that it is my responsibility as a participant to follow the safety standards, guidelines, and procedures established by the staff/instructor at any time I realize it is my responsibility to ask for clarity and/or assistance.
In signing this document, I authorize the leader of the activities to secure such medical advice and services as deemed necessary for my health and safety and agree to accept financial responsibility:
-Where my health and well-being is involved
-Where medical advice has been such that further services are required
-Where all reasonable attempts to contact family have failed or where the nature of the emergency does not allow time to make contacts
-Where the benefits of my provincial health insurance plan have been exhausted and additional loss of income and/or medical expenses are incurred.
I understand and assume all dangers and risks associated with this course and waive all claims against NPRCC staff and assigns, it’s officers, shareholders, employees, volunteers, agents and their heirs, executors and assigns, for any incidents that should occur due to my voluntary participation in this experience. Furthermore, I give my consent to the instructors or other medical personnel to treat me in a medical situation. My signature on this document is also intended to bind my successors, heirs, representatives, administrators and assigns.
Participant’s Signature_____________________________________Date________________
FORM #2
NPSDRCC
MEDICAL DISCLOSURE/HEALTH FORM
We require that this form be filled out in full.
Name:________________________________________________________________________
Address:_____________________________________________________________________
_______________________________________________________________________
Phone:_______________________________________________________________________
Age:_________________________
In case of emergency please notify:
Name:________________________________________________________________________
Phone:_______________________________________________________________________
Relationship:__________________________________________________________________
Physicians Name:______________________________________________________________
Physicians Phone:_____________________________________________________________
Medical Policy and Number:_____________________________________________________
1. Do you smoke? _____Yes _____Number of packs per day _______No
2. Do you wear glasses or contacts? _____Yes _____No
3. Are you currently under a physicians care? _____Yes _____No
If yes, please explain:____________________________________________________
4. Are you currently taking medication? _____Yes _____No
If yes, explain:__________________________________________________________
5. Do you have allergies? _____Yes _____No
If yes, explain:__________________________________________________________
6. Do you require special assistance of any type? _____Yes _____No
If yes, explain:__________________________________________________________
7. Have you had a recent injury, illness, or operation? _____Yes _____No
If yes, explain:__________________________________________________________
8. Do you have diabetes, seizures, frequent fainting/dizziness? _____Yes _____No
If yes, explain:__________________________________________________________
9. Do you have any neck, back, or shoulder pain or injury? _____Yes _____No
If yes, explain:__________________________________________________________
10. Does your weight present health problems or limit physical activities?
_____Yes _____No
If yes, explain:__________________________________________________________
11. Do you have a history of heart problems or high blood pressure?_____Yes _____No
If yes, explain:__________________________________________________________
***If you have checked yes to #11 please note the information on the following page.
Participant’s Signature:__________________________________________Date___________
Form #3
Participants with a history of heart problems and/or high blood pressure are at risk while participating on the RCC due to the emotional and physical demands involved. Whereas heart attack and fatalities have occurred in situations where individuals with pre-existing heart/high blood pressure conditions have participated in RCC activities, NPRCC cannot guarantee your physical safety should you choose to participate. NPRCC asks that all participants answering YES to question #11 acquire a written approval from their physician prior to participation.
For General Information Regarding Pregnancy, please note the following:
The activities involve twisting, turning, lifting, supporting body weights, unexpected physical contact, potential falling from various heights, and waist harness usage. By participating in these activities while pregnant, you will put yourself and your unborn child at risk and in potentially dangerous situations. Should you decide to participate, NPRCC cannot guarantee the safety of you or your unborn child. If you are pregnant and wish to participate, NPRCC asks that you attain a physician’s written approval.
I have read the NPRCC Health Forms (Forms 2 and 3) and fully understand them without question. The information I provided is accurate to the best of my knowledge.
Participant’s Signature__________________________________________Date____________
By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against NPRCC on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
Signature of Participant:___________________________________
Check one:______18 years of age or older ______Under 18 years of age (Parent/Guardian consent required)
Print Name:_____________________________________________
Address:_________________________City:____________________State:_______Zip:_______
Phone:________________________Date:_________________Birth Date___________Age____
Parents or Guardian’s Additional Indemnification
(Must be completed for participants under the age of 18)
In consideration of______________________________(print minor’s name)(“Minor”) being permitted by NPRCC to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless NPRCC from any and all Claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.
Signature of Parent or Guardian:___________________________________Date:____________
Print name of Parent or Guardian:__________________________________________________
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