Release and Assumption of Risk Agreement

Transcription

1 Release and Agreement Rationale & Purpose Safety is a fundamental concern of The Mountain Institute (TMI). Despite operating activities and programs to the best of our capabilities, TMI s course activities have inherent risks which may result in harm or injury to our participants. There is no way to reduce that possibility to zero. The purpose of this form is threefold. First, it is to inform you of the types of course activities and environments in which you will participate. Second, it is to inform you of some, but not all, of the inherent risks associated with those activities and environments. Third, it is to have you acknowledge and assume those inherent risks known and unknown, anticipated and unanticipated associated with course activities and environments. Acknowledgement of Risk In consideration for being allowed to participate in the services of TMI, its employees, groups, representatives or agents and all other persons or entities acting on TMI s behalf, the following terms apply. I acknowledge: During the course in which I am participating, certain inherent risks, both known and unknown, may occur. The activities and environments that contribute to the unique character of this course can be causes of loss or damage to my equipment, accidental injury, illness, or in extreme cases, permanent trauma, disability, or death. I understand that TMI does not want to frighten me or reduce my enthusiasm for this course, but thinks it is important for me to know in advance what to expect and to be informed of the inherent risks. Courses may occur in remote places, many hours from medical facilities. Communication and transportation can be difficult and sometimes evacuations and medical care may be delayed. Travel is by vehicle, canoe, and on foot over rugged and unpredictable terrain, including stream crossings, snow and ice, steep slopes, slippery rocks, and downed timber. Activities vary from course to course, including but not limited to the following: hiking, backpacking, climbing, caving, camping, canoeing, and stream sampling. Participation in these activities entails certain inherent risks, including but not limited to: burns (including chemical burns), cuts, diarrhea, flu-like illnesses, hypothermia, frostbite, sunburn, heatstroke, dehydration, waterborne illnesses, strains, sprains, fractures, and injury due to rapidly moving, deep or cold water, potential exposure to insects and parasites, rolling or falling rocks, lightning, and floods. Updated January 2015 Page 1 of 5

2 I am aware that TMI courses include inherent risks of injury or death to myself. I understand the above description of these inherent risks is not complete and that other unknown or unanticipated risks may result in property loss, injury, or death. I expressly agree and promise to accept and assume all the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary, no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. Acceptance of Responsibility Instructors will do their best to manage the safety of the entire group and to promote the importance of group members looking out for one another s safety. Ultimately, each member of the group is responsible for contributing to their own and the other participants safety. I accept that I am expected to contribute to my own personal safety and that of others in the group. To this end, I am expected to pay attention to and follow instructions and safety guidelines, to behave in a responsible manner consistent with TMI s rules, and to ask questions if I am concerned about my safety and comfort. Waiver/Release of Liability I hereby voluntarily release and forever discharge TMI, its employees, groups, representatives or agents and all other persons or entities acting on TMI s behalf from any liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this course, including specifically but not limited to the negligent acts or omissions of TMI, its employees, groups, representatives or agents and all other persons or entities acting on TMI s behalf for any and all injury, death, illness or disease, and damage to myself or to my property. Agreement to Hold Harmless & Indemnify I further agree, promise and covenant to hold harmless and indemnify TMI, its employees, groups, representatives or agents and all other persons or entities acting on TMI s behalf from all defense costs, including attorney s fees, or from any other costs incurred in connection with claims for bodily injury or property damage which I may negligently or intentionally cause to other third parties in the course of my participation in this event. Updated January 2015 Page 2 of 5

3 Enforceability I understand that this is the entire agreement between myself and TMI, its employees, groups, representatives or agents and all other persons or entities acting on TMI s behalf, and that it cannot be modified or changed in any way by the representation or statements of any employee or agent of TMI, or by me. If any portion of this agreement is unenforceable, the remaining portions shall remain in full force and effect. My signature below indicates that I have read this entire document, understand it completely, and accept and agree to be bound by the terms and conditions stated herein. I further accept and agree that this Acknowledgement and, Waiver/Release of Liability, and Agreement to Hold Harmless and Indemnify shall be effective and binding on myself, my heirs, assigns, personal representatives, and estate and all members of my family. Participant's Name (Print): Participant's Signature: Date: If under 18 years of age, parent or guardian must read and sign below: I am the legal guardian of the above minor and have read the above ACKNOWLEDGEMENT. I hereby consent to the terms of the ACKNOWLEDGEMENT on behalf of the named minor, and give my consent to the participation of the above named minor in all activities of TMI on the terms stated. I am familiar with the Minor s experience and capabilities, and believe the Minor to be qualified to participate. I hereby personally accept and undertake, individually and in my own name, all of the obligations stated above specifically including the release, assumption of risk, and hold harmless provisions as to the Releasees of all liability, claims, demands, losses and damages suffered or alleged to have been suffered or incurred by the Minor or to others resulting from injury to the Minor. Parent or Guardian's Name (Print): Updated January 2015 Page 3 of 5

4 Participant Medical Release Participant Info Participant Name: Date of Birth: Age: Height: Weight: Sex: M / F Address: City/State/Zip: Emergency Contact Info Name: Relationship to Student: Phone: Home: Cell: Work: Physician/Insurance Info Name: Phone: Insurance Company: Policy #: Allergies/Dietary Restrictions Please list all allergies to insects, foods, medications, etc. Include any dietary restrictions as well (vegetarian, vegan, no pork, etc.). Attach extra page if needed. Allergy/Restriction Reaction Medication Required Current Medications Please list all medications that the student is currently taking. All prescription medications must be sent with the student in their original containers with physician s directions. If you are sending an Epipen, please send two, as well as the appropriate dose of oral Benadryl due to our remote location. Attach extra page if needed. Medication Condition Taken For Dosage Side Effects Student Medical Release Updated January 2015 Page 4 of 5

5 Current and Recent Medical Conditions Please list all medical conditions that the student has been diagnosed or treated for within the past year. Include any injuries, illnesses, psychiatric treatment, counseling, eating disorders, attention deficit disorders, etc. If diabetic, please include contact information for diabetic nurse/physician. Attach extra page if needed: Date of Last Tetanus: Asthma Diabetes Medical Release I understand that (your child s school) and The Mountain Institute (TMI) will take every reasonable precaution against accident or injury during the school trip. If a medical emergency occurs involving my children in route to or from or while participating in TMI programs and I cannot readily be reached, the school or TMI may select any licensed physician to secure and administer medical treatment, including hospitalization and surgery for the child if and as needed. I understand any medical expense so incurred will be my financial responsibility. I understand that my child is under the authority of (your child s school) during the trip and that school rules are in effect. I have listed all the information concerning allergies, medical history or conditions, dietary restrictions and regular medication that my child may take. Parent or Guardian's Name (Print): Permission to use Images The Mountain Institute relies on the use of images of program activities and student feedback for recruitment purposes, as well as to report to and solicit financial donors. TMI staff often take photographs informally throughout the duration of a program and these serve as our image library. Also, students are asked to complete evaluations at the end of a course. By signing below you agree that The Mountain Institute has the right to use pictures or statements by, of, or about your child for aforementioned uses. Connect with The Mountain Institute The Mountain Institute sends occasional news and upcoming events updates. If you are interested in joining our electronic and/or physical mailing list, please enter your information below. Name: Yes, please send updates to the physical address above. Yes, please send updates to my address: Please do not send me anything. Nondiscrimination Policy The Mountain Institute follows a policy of uniform nondiscrimination with regards to sex, age, race, religion, and country or origin. Student Medical Release Updated January 2015 Page 5 of 5