I release all officials and professional personnel from any claim whatsoever on account of first aid, treatment or service rendered to my child during participation in these activities. This release contains the entire agreement between the parties. I give permission to pastoral leaders to secure emergency medical and surgical treatment. Also to provide routine, non-surgical medical care for the minor child named above while attending the retreat. I understand that if my child develops a fever that continues at 100° or above, he/she will need to be sent home. Also, the pastoral leaders may deem it proper to send my child home in the event he/she develops certain other illnesses or sustains certain injuries. This will necessitate me coming to Higher Ground Conference and Retreat Center to transport my child home, or to arrange for his/her transport. Further, I understand that a decision to send a child home is not made lightly, and is made with the good of the individual child and other participants in mind.

I agree all of the above information is accurate and the terms of this release are contractual and not a mere recital.

ALL MEDICATIONS MUST be in the original package. ALL PRESCRIPTION MEDICATION MUST have the prescription label, including dosage. Please list all medication your student will be taking while at the retreat. Please only send the amount of medication needed for this trip.

Note: All medicine will be administered by the adult leader from the church. There will not be a nurse on site.

There is a $50 non-refundable fee for cancellations before June 1st . After June 1st, no refunds are avilable.

PLEASE READ THE FOLLOWING BEFORE SIGNING:

WHEREAS, THE UNDERSIGNED (“the APPLICANT”) wishes to be accepted for participation in a Ropes Course/Challenge Course Training Workshop or other Adventure-based program to be organized and conducted by Higher Ground Conference and Retreat Center of West Harrison, Indiana: and in consideration of Higher Ground’s action in allowing the applicant to participate in such a program. The applicant also allows use of their photo and/or comments for print materials: The undersigned acknowledges that during the said workshop or program that the Applicant has requested to participate in, that certain risks and dangers exist. These include, but are not limited to, the hazards of traveling terrain, depending on other people and being at various heights (ground to over 40’), accident or illness in remote places without medical facilities, the forces of nature and travel by air, train, boat, automobile or other conveyance.

The undersigned further recognizes that these risks may also include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to accidents which may occur, including accidents resulting from this course experience or other type of outdoor activities. I further understand that participation in the activities I am requesting to participate in, I will be exposed to the effects of natural elements, including temperature extremes and inclement weather. I certify that I am completely healthy (both physically and emotionally) and capable of participating in this workshop or program. I have listed on the Health Statement Form any medical condition that Higher Ground should be aware of, which may hinder my participation in the Workshop. However, I understand that it is solely my responsibility to determine whether there is any medical reason that I should not participate in the workshop, and I do not rely on Higher Ground for any assessment of my health or ability to participate in these activities.

In consideration of, and as part payment for the right to participate in such a program and the services arranged for me by Higher Ground, its Shareholders, Directors, Officers, Employees, Agents, and/or Associates (hereafter referred to collectively as “Higher Ground”), I have and do hereby assume all the above risks and any other ordinary risk incidental to the nature of the trip/training, which are not specifically foreseeable, and, for myself, my representative, assigns, heirs, and next of kin, will release and HOLD HARMLESS Higher Ground from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss or otherwise, whether caused by negligence of Higher Ground or otherwise, which I now have or which may arise from or in connection with my program or participation in any other activities arranged for me by Higher Ground, its Shareholders, Directors, Officers, Employees, Agents and/or Associates, and their heirs, executors and administrators, successors and assigns and for all members of my family, including any minors accompanying me.

In short, I cannot sue Higher Ground and if I do I cannot collect any money. In addition, I will be liable for Attorney and Court fees associated with any litigation against Higher Ground. I also state that I am not under, and will not be under the influence of any chemical substance including alcohol. I fully understand that my physical activity involves risk of injury. I also understand that my participation in this Higher Ground activity is completely and entirely VOLUNTARY. I enter this workshop and take full responsibility for my decision to participate or not to participate and agree to follow all safety instructions. I hereby give permission to the medical personnel selected by Higher Ground to order injections and/or anesthesia and/or surgery for me. Such authorization for emergency treatment shall also include, but not be limited to: charges incurred for the providing of aid and arranging evacuation if Higher Ground or its agents, determined that such evacuation is necessary or desirable.

I further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned. I also understand and agree to abide by any restrictions placed on my activities.

Please fill this form out to the best of your knowledge. Some information will be filled in from previous answers (such as name, address, date of birth, etc.)

NOTE: IF YOU HAVE EVER HAD ANY HEART RELATED PROBLEMS YOU WILL NEED TO HAVE A RELEASE FROM A PHYSICIAN IN ORDER TO GO THROUGH A HIGH ELEMENT TRAINING.

REPRESENTATION AND EMERGENCY AUTHORIZATION

This health history is correct so far as I know, and believe that my health is satisfactory or participate in challenge course activities. I hereby give permission to the medical personnel selected by Higher Ground to order injections and/or anesthesia and/or surgery for me. Such authorization for emergency treatment shall also include, but not be limited to; charges incurred for the providing of aid and arranging evacuation if Higher Ground or its agents, determined that such evacuation is necessary or desirable. I further agree to assume responsibility for the costs of any specialized means of evacuation and of any medial care I release all personnel from any claim whatsoever on account of first aid, treatment or service, whether deemed negligent or otherwise, rendered me during participation in ropes courses/rock climbing.