October 27-28, 2023 BLAST! Hike-a-thon

CONFIDENTIAL MEDICAL HISTORY AND MEDICAL AUTHORIZATION

Participant and guardian must read and sign this entire form. This completed and signed form must be on file for the camper to participate in activities with Discovery Ministries, 17043 State Route E, Eminence, MO 65466, 573-226-3213
Participant Basic Information
Group/Trip Name*
Retreat/trip start date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Zip Code
State*
Zip Code*
Phone*
Please enter a valid phone number.
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Age*
Sex*
Today's Date

MonthDayYear
Date
Weight in lbs.*
e.g. 6
Height: Feet Feet*
Inches Inches*
T-Shirt Size*

Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult 2XL
What is your mileage goal?*
Emergency Contact
Emergency Contact*

First NameLast Name
Relationship with Emergency Contact*
Their relationship to you (e.g. "Mother")
Emergency Contact Address*

Street Address

Street Address Line 2

CityState (2 letter postal abbreviation please)

Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Physician Information
Physician's Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.
Physician's Address

Street Address

Street Address Line 2

CityState

Zip Code

Liability Waiver and Acknowledgment of Risk
In consideration of the services of Discovery Ministries, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "DM"), I hereby agree to release, indemnify, and discharge DM, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that my participation in outdoor adventure based activities such as camping, caving, backpacking, rock climbing and rappelling, canoeing, challenge course events, group initiatives, and traveling to and from an activity entails known and unanticipated risks which could result in sickness, exposure to infectious/communicable disease, bodily injury, paralysis, death, emotional injury, personal injury, property damage, damage to myself or third parties, and financial damage. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. Furthermore, DM guides/instructors/facilitators have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They might misjudge the weather, the elements, or the terrain. They may give inadequate warnings or instructions, and the equipment being used might malfunction.
*

I have read, understand and agree to the above statement.
2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
*

I have read, understand and agree to the above statement.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless DM from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity, my use of DM's equipment, or my use of DM’s facilities or property, including any such Claims which allege negligent acts or omissions of DM.
*

I have read, understand and agree to the above statement.
4. Should DM or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
*

I have read, understand and agree to the above statement.
5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I have no medical or physical conditions which could interfere with my safety in this activity, or else I am willing to assume -- and bear the costs of -- all risks that may be created, directly or indirectly, by any such condition.
*

I have read, understand and agree to the above statement.
6. In the event that I file a lawsuit against DM, I agree to do so solely in the state of Missouri, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
*

I have read, understand and agree to the above statement.
7. I agree to allow DM to use any photos of me for public relations unless I have selected otherwise.

I agreeI do not want pictures used
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 DM on the basis of any claim from which I have released them herein. I understand itineraries are subject to daily change due to circumstances. Activities may be postponed or canceled at the last minute.

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:*

Clear
PARENT'S OR GUARDIAN'S ADDITIONAL INDEMNIFICATION

(Must be completed for participants under the age of 18)

In consideration of {input316:shorttext-1} ("Minor") being permitted by DM to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless DM 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 Legal Guardian:

Clear
Electronic Signature Release Statement*

I agree to the electronic complete and signing of this/these form(s). I understand that the information will be transmitted and potentially stored further via electronic means. Further, I understand and agree that this/these electronically signed form(s) shall be deemed to have the same legal effect as an original copy/copies for all purposes.
*Printable copies of blank forms may be obtained by contacting Discovery Ministries directly.

40th Anniversary RSVP
Will you be staying for the 40th Anniversary Celebration on Sunday, October 29, 2023?*

YesNo
Will you need lodging Sunday night?*

YesNo
How many family members will be joining you for the 40th?*
Please list names of all family members joining you.*
Should be Empty:

CONFIDENTIAL MEDICAL HISTORY AND MEDICAL AUTHORIZATION

Participant Basic Information

Emergency Contact

Physician Information

Do You Regularly Have or Have You Had Any of the Following Conditions or Symptoms?

Hospitalizations/Emergencies

Medications

Allergy

Personal History

Liability Waiver and Acknowledgment of Risk

40th Anniversary RSVP