Activity Release Form - Waiver, Agreement, & Liability Release printable pdf download

ACTIVITY RELEASE FORM | Waiver, Agreement, & Liability Release

Read carefully before signing. One signed copy required for each individual who participates in an activity.

Camp Carl’s programs involve a variety of activities that often include warm-ups, games, group initiative

problems, the climbing tower, high and low rope challenge course elements, horseback riding, and other rig-

orous physical adventure activities. (The level of participation in a Camp Carl program activity is at all times

completely to the individual’s choice.) Yet, there is a risk, which must be assumed by each participant that he

or she may suffer an emotional or physical injury, disability, or loss of life.

Policy for participation in these activities requires certain health/medical information be made known to the instructor(s) conducting the pro-

grams, so that they are prepared to respond appropriately should the need arise.

This information will be held in confidence. Please complete the form and return it to the Camp Carl staff member facilitating the event in

which you are participating.

PARTICIPANT INFORMATION

Participant’s name (please print legibly) ____________________________________________________________________________________

Parent’s phone #1 ____________________________________________ phone #2 ________________________________________________

Parent’s address ______________________________________________________________________________________________________

Does participant have health insurance? Yes No If yes, indicate name of company. ____________________________________________

Does the participant have limiting physical disabilities/handicaps (temporary or permanent)? ________________________________________

Is the participant currently taking medication (prescribed or over the counter)? Yes No

If yes, state what medication the participant is taking and why. __________________________________________________________________

Does the participant have any allergies, reactions to medication, any medical/physical limitations or fear of heights, horses etc that may cause a

mishap? Yes No If yes, please explain. ________________________________________________________________________________

RELEASE STATEMENT

I understand that parts of these activities may be physically or emotionally demanding. I affirm that I (or the participant) am in good health and

am not under a physician’s care for any undisclosed condition that bears upon my (or their) ability to participate in this activity. I understand

that The Chapel/Camp Carl will provide safety equipment such as helmets and life jackets, as needed, for the activities that require it. I recognize

the inherent risk of injury or disability and understand that each participant must assume the risk of physical injury that could result. I release

The Chapel/Camp Carl, its staff members, and Board of Trustees from any liability for any injury resulting from participation in these activities.

This release is governed by the State of Ohio.

EQUINE SECTION

Read carefully before signing. One signed copy required for each individual who participates in an activity.

I agree to the following Waiver, Agreement, and Liability Release with The Chapel/Camp Carl, as a condition for its allowing me, and the other

persons identified below, to do any of the following: enter any premise or facility where The Chapel/Camp Carl may conduct activities (referred

to herein as “The Property”), be near horses in connection with any The Chapel/Camp Carl activity (regardless of who owns the horses) and/or

engage in any other activity involving horses. I am making this Agreement regardless of whether these activities take place under the supervision

of The Chapel/Camp Carl.

All parts of this Waiver, Agreement, and Liability Release shall apply to me, and the children/legal wards listed above. (We will collectively call

ourselves “I, ” “me, ” or “my” throughout this document.) This Waiver, Agreement, and Liability Release will be binding at all times, now and in

the future, even after my relationship with The Chapel/Camp Carl should end.

IT IS HEREBY AGREED AS FOLLOWS

1. I have requested to enter the premises, land, structures, or facilities where The Chapel/Camp Carl may conduct any activities (referred to

herein as “The Property”), to be near horses in connection with any The Chapel/Camp Carl activities (regardless of who owns the horses), and/

or to engage in any other activity involving horses, whether or not under The Chapel/Camp Carl’s supervision.

2. Equine-Related Risks: I understand that anyone riding, handling, or even near a horse (referred to as “equine”) can suffer bodily and other

injuries. Among other things, equines are unpredictable by nature. For example, when frightened, angry, or under stress, the natural instincts of

(over)

Activity Release Form - Waiver, Agreement, & Liability Release

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