Chapel Rock Release of Liability

Chapel Rock Participant Information and Release of Liability Form

DISCLOSURE: Chapel Rock programs involve a variety of activities that often include warm-ups, games, group initiative problems, high and low ropes course elements, rock climbing, rappelling, kayaking, orienteering, and other rigorous physical adventure activities. (The level of participation in a program activity is at all times completely up to the individual Trained professional staff conducts all programs; yet there is a risk which must be assumed by each participant that he/she may suffer an emotional or physical injury, disability or death. Every participant in Chapel Rock programs is encouraged to have health/accident insurance coverage. In addition, certain health/medical information must be made known to the instructor(s) conducting programs, so that they are prepared to respond appropriately if the need arises. This information will be held in confidence. Please complete this form and return it to Chapel Rock prior to participating in any activities. High ropes activities have a weight minimum of 45lb and a maximum of 275lb, and by participating in our high ropes you acknowledge that you are between these.

1. Group Name

2. Name*

Date of Arrival*

Date

Date of Departure*

Date

3. Do you have any limiting physical or mental disabilities or medical restrictions (temporary or permanent) that could hazard yourself or others during the duration of this program? If yes, identify and explain*

4. Do you have any allergies, reactions to medication, or any other medical limitations? If yes, identify and explain:*

5. Have there been any recent or major life changes? (E.g. Job changes, death in family, etc.)*

RELEASE OF LIABILITY: I understand that parts of the Chapel Rock program may be physically or emotionally demanding. I affirm that my health is good, and that I am not under a physician's care for any undisclosed condition thatbears upon my fitness to participate in Chapel Rock activities. I understand that each participant must assume the risk of physical injury that could result from any of these activities. I release Chapel Rock, and its staff members, from all liability for any injury to me from participation in Chapel Rock activities.

Date*

Date

Signature*

PHOTO/MEDIA RELEASE: I grant to CHAPEL ROCK, and persons acting for or through them, the rights to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of myself for use in materials they may create.

Date

Signature

Are you filling this out for a minor?*

YesNo

PARENTAL WAIVER OF CLAIMS: Parental permission must be secured for participants who are not of legal age (18 years If you are not yet classified as a legal adult, your parent(s) or legal guardian(s) must complete the following:

I/We

(parents' or guardians' name)

give permission for my (our) child

(child's name)

to participate in the Chapel Rock program and associated field trip(s) Should my/our child become injured, I/we request that the trip leader or designated Chapel Rock staff secure emergency medical services to aid my/our child, if in their judgment such services are necessary. I/we agree to incur any additional expenses associated with such action. As parents/guardians, I/we have decided (with or without medical advice) that my/our child is physically, mentally, and socially able to participate, and I/we acknowledge that any medical or accident insurance we consider necessary will be my/our responsibility to locate and purchase. Furthermore, I/we have read all sections of this form and do hereby release Chapel Rock and its employees from liability for any damages, injuries, or losses which may occur while said child is participating in this Chapel Rock program.

Date

Parent or Guardian Signature (if participant is under age 18)