CLARK COUNTY PARKS RECREATION

CLARK COUNTY PARKS AND RECREATION CAMP LEE CANYON CHALLENGE COURSE PARTICIPANT INFORMATION FORM & LIABILITY RELEASE

The challenge course involves a variety of activities including warm-ups, games, group initiatives, low and high course elements, and other rigorous physical activities in a wooded, outdoor, 8,500 feet altitude setting. The level of participation during each activity is completely voluntary. Highly trained staff, maintenance of state- of-the-art equipment, and strict safety standards safeguard all participants and facilitators against possible injury. As with any program of this type, there is a risk that must be assumed by each participant that he/she may suffer an emotional or physical injury or disability. MEDICAL INFORMATION (information to be completed by parent or guardian if participant is under 18 years of age): Please answer all information thoroughly and honestly. This information is important for your safety, and will not be used as a screening process to exclude you from the program. Certain health/medical information must be made known to the facilitator(s) conducting the program so that they will be prepared to respond appropriately if the need arises. Participant or parent (if child is under 18 years of age) will be responsible for knowing their medical condition and whether it will prohibit them from safely participating in any challenge course activities. Under certain circumstances, a medical release from your physician may be required. This information will be kept confidential unless needed in an emergency situation.

Participant print full name*

Participant Age*

If over 18 participant name

If Under 18 Parent/Guardian Name*

Date of challenge course activity*

Date

Date of challenge course activity*

Date

Name of Group*

Contact email*

example@example.com

Address*

Emergency Contact*

Emergency Contact Phone #*

Emergency Contact Relationship*

Physician Name*

Physician Phone*

Medical Insurance Provider*

Policy Holder*

Policy number*

Do you Smoke*

YesNo

# of packs day*

Do you wear glasses?*

YesNo

Are you currently under a physician's care?*

YesNo

For what?*

Do you have any allergies?*

YesNo

What are the allergies?*

Do these allergies require an epi-pen*

YesNo

Have you had a recent injury, illness, or operation?*

YesNo

What was it?*

Do you have diabetes, seizures, frequent fainting/dizziness?*

YesNo

Explain?*

Are you on medication for any of the above?*

YesNo

Do you have any head, neck, back, shoulder pain or injury?*

YesNo

Explain?*

Do you have history of heart problems, high blood pressure, or hemophilia?*

YesNo

Explain?*

Are you taking any medication for any above condition?*

YesNo

Do you have a developmental disability, autism, cognitive disability or other mental illness?*

YesNo

Explain?*

Do you have history of lung disease, asthma, or breathing problems?*

YesNo

Explain?*

Do any of the require medication (inhaler, etc?)*

YesNo

Do you have arthritis or any other joint pain or disease?*

YesNo

Explain?*

Do you have any bowel/bladder control problems?*

YesNo

Are you currently taking any medication?*

YesNo

If yes what medication and for which condition which it has been prescribed?*

Do you require special assistance of any kind?*

YesNo

Explain*

Anything else we should know?*

YesNo

Explain*

I acknowledge on behalf of myself or my minor child that part of the Lee Canyon Challenge Course may be physically or emotionally demanding. I affirm my health is good and that I am not under a physician's care for any undisclosed condition that might endanger my health or the health of other participants.l recognize the inherent risk of injury or disability, even death in Challenge Course activities. It is further understood that unforeseen circumstances may arise for which Clark County, Nevada shall not be held responsible. The undersigned acknowledges that they have read the Challenge course checklist provided by Clark County Parks & Community Services, and accept full responsibility for the result of inadequate clothing or equipment and for clothing and equipment which I fail to provide.

I hereby voluntarily assume and accept all personal responsibility for my or my child's behavior, and for all risk of injury, illness, disease or death, and release any rights or claims for damages and agree to indemnify, defend, and hold harmless CLARK COUNTY, its faculty, agents, and all individuals assisting in facilitating and conducting these activities, from all liability of any nature for any and all injuries, loss or damage suffered at, or in any way connected to participation in this program. This does not preclude SIIS claims from Clark County and other government employees. My signature below will also indicate that I have been informed about the nature of Challenge Course activities, and I will participate in only those activities that are within my abilities and limitations. I have read, understood and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding hereafter. EMERGENCY MEDICAL RELEASE (parents/guardian only): If I cannot be reached in an emergency, I hereby authorize Clark County personnel to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child.

Date*

Date

Participant Signature*

ParentGuardian Signature*

Doctor's notes are required to participate in activities for participants who answered "yes" to questions 3, 5, 7, and/or

Preparing for a day on the Camp Lee Challenge Course

As you prepare for your adventure on the Clark County Parks and Recreation Challenge Course, please be aware that barring inclement weather, you will be outdoors for the duration of your activity. Please keep in mind that Lee Canyon is on average 20-30 degrees cooler than the Las Vegas Valley, and is prone to sudden rainstorms in the summer. Dressing in layers and anticipating weather changes will add to your comfort and enjoyment! Please dress to be active and clothes and shoes that are comfortable and durable. Sun, wind, rain, heat, or cold can all be part of a day on the course- please be prepared!

Shoes: close-toed with rubber soles. Tennis shoes are ideal.

Loose, casual, comfortable clothing that covers you but lets you move. T-shirts, long-sleeve t-shirts, sweatshirts, long shorts, or long pants are all good choices depending on the weather and your

Layer clothing for the weather and bring rain gear just in case.

Release form (if you did not submit it prior to)

Epi-pen, inhaler, etc. Lunch/snacks

Jewelry and valuables: Rings, earrings, and necklaces can be broken or pose a hazard. Please remove jewelry before arriving on the course. Cell phones: There is no service at Camp Lee, so we advise you leave your phone at home. If you choose to bring it to take photos, it must remain outside of the boundaries of the course for safety. Gum: gum can pose a choking hazard, be a distraction, and cause harm to local flora and fauna.

To maximize your experience on the course, we ask that your group please arrive on time and ready to participate!