Epiphany Experiential Team Development-Participant Information

Epiphany Experiential Team Development-Participant Information

Group/Organization’s Name:______Date of Program______

Group Leader______Title______

Phone Number______Email Address______

Participant’s Name______Date of Birth______Gender______

Street Address______

City______State______Zip Code______Phone Number______

Emergency Contact Information

Primary Contact

Name______Relationship______

Cell Phone______Other Phone Number______

Secondary Contact

Name______Relationship______

Cell Phone______Other Phone Number______

Medical Information

Is participant covered by medical/accident insurance? ______No _____Yes Name of Insurance Company______

Address of Insurance Company ______

Policy Number______

Does participant have any medical or physical conditions that may impact their participation? ______No ______Yes

If yes, please explain:______

______

Is the participant currently taking any medications? _____ No _____ Yes If yes, please list the medication(s) ______

______

Does the participant have any allergies? _____No _____ Yes If yes, please list the allergies ______

______

Does participant have an inhaler? ______No ______Yes Does participant have an Epipen? ______No ______Yes

Any additional information that would be helpful:______

______

______

Epiphany Experiential Team Development Risk and Liability Agreement

Group Name______Program Date(s)______

Group Leader______Title______

As a participant in an Epiphany Experiential Team Development program, I acknowledge the nature of the physical activities involved and I acknowledge, appreciate and agree that;

The physical activities may include but are not limited to:

• Physically supporting and being physically supported by other individuals in the group
• Traversing obstacles on cables, wires and wooden boards
• Heightened cardio-vascular usage
• Utilization of “climbing” equipment (i.e. harnesses, ropes, etc.)
• Climbing walls, poles and other obstacles three feet and higher above the ground

I understand that, although particular guideline/rules, safety equipment, and knowledgeable professionals are employed in Epiphany Experiential Team Development programs, there is a significant risk of injury from participating in the activities involved in this program; and

I willingly agree to comply with the rules/guidelines of participation in the program. If, however, I observe any unusual significant hazard during my participation, I will remove myself from participation and bring such to the attention of the nearest staff member; and

I knowingly and freely accept all risk and responsibility both known and unknown, even if arising from the negligence of the facilitators, or others involved, and assume full responsibility for my participation. I understand that my pre-existing conditions, whether known or unknown, could be exacerbated by my participation, and I fully accept and assume these risks; and

I, for myself and on behalf of my heirs, personal representatives, and next of kin, herby release indemnify, and hold harmless Epiphany Experiential Team Development staff, vendors, sponsoring agencies, owners and lease holders of premises used to conduct activities, with respect to any and all injury, disability, death, damage, or loss to person or property, whether arising from the negligence of the releaser or otherwise, to the fullest extent permitted by law.

I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily.

Participant’s Name______Date______

Signature______

For Parents/Guardians of Participants under age 18

Parent/Guardian Name______Date______

Parent’s Signature ______