Disclosure Form

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Disclosure Form

I.YMCA Tockwogh Challenge Course. I have read all of the information regarding the challenge course, and I have voluntarily chosen to participate in the program conducted by YMCA Tockwogh. The nature of the activities has been made clear to me through the information in this packet, and in consideration of the benefits of this program I agree to the following:

II.Disclosure and Identification of Risks. I understand that YMCA Tockwogh’s challenge course programs operate primarily outdoors. It will operate in a variety of weather conditions, in many physical settings, and with diverse people. Because of this, I understand that I may be exposed to various risks, hazards, and stresses. Many of the activities involve physical risks and stresses that include, but are not limited to; climbing, walking on uneven ground, standing for long periods, running, jumping, lifting, pulling, pushing, balancing, throwing, and catching. Furthermore, weather and other forces of nature may create additional hazards and risks such as, but not limited to; darkness, heavy rain, snow, ice, lightning, wind, extremes of heat and cold, biting insects, and other wildlife. Stresses may result from many factors including, but not limited to; emotional anxiety, interpersonal conflicts, and any fears or phobias.

III. Acknowledgement of Risk. I understand that even though YMCA Tockwogh has taken reasonable precautions to ensure a safe educational environment including providing proper equipment, suitable facilities, and trained staff, it is impossible to guarantee absolute safety. I acknowledge the inherent risks of YMCA Tockwogh’s Challenge Course and agree to assume those risks.

IV.Assumption of Personal Responsibility. I accept that I am responsible for my safety while a participant at YMCA Tockwogh, and I am willing to assume that responsibility. This means I agree to follow all directions from YMCA Tockwogh staff, and agree to act carefully and with good judgment at all times. I also verify medical information to the best of my knowledge on the Medical Information form.

V.Waiver and Release. I understand YMCA Tockwogh’s Challenge Course to be a physically and mentally challenging program conducted in the outdoors. I have been made aware of the risks and am willing to assume them. As a result, I waive, release, and discharge any and all claims for damages of death, personal injury, or property loss which may result from my participation in this program. I understand that these injuries and losses may occur as a result of the actions of other participants as well as myself. I hereby hold YMCA Tockwogh and its staff harmless and release YMCA Tockwogh and its staff from any liability or claims arising from any accident or stressful incident, except where caused by the gross negligence or wanton misconduct of the released parties. I intend this waiver and release to apply to any relatives, heirs, next of kin, or personal representatives who might pursue any legal action or claim on my behalf.

I have read this form carefully and I am signing it voluntarily

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Medical Information

1. General Information

Name: ______

Male Female D.O.B. ______Age: _____ Occupation: ______

Street Address: ______City/State/Zip: ______

Home Phone: ______Office Phone: ______Email: ______

2. Emergency Information

In case of an emergency, please contact these people

Name: ______Relationship: ______Phone: ______

3. Insurance Information

Medical Insurance Company: ______Policy Number: ______

Street Address: ______City/State/Zip: ______

Phone Number: ______

4. Medical Information

Allergies: ______Medications: ______

1. Pregnant?Yes No2. Seizure within past year?Yes No

3. Heart problems?Yes No 4. Recent hospitalization? Yes No

5. Neck/Back problems?Yes No6. Joint/Muscle problems?Yes No

Describe any medical conditions YMCA staff needs to be aware of: ______

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5. Cardiac Information

1. Do you smoke?Yes No2. Personal history of heart disease?Yes No

3. High blood pressure?Yes No 4. Frequent chest pains?Yes No

5. Asthma? Yes No6. Family history of heart disease?Yes No

7. Hypertension?Yes No8. Do you take cardiac medication?Yes No