|
Challenge
Mountain
of Walloon Hills, Inc.
2205 Springbrook Rd.
Boyne Falls, MI
49713
(231)535-2141, Lodge - 231-582-1186 Admin
Mailing address 01158 M-75 South, Boyne City, MI 49712
Permission for Emergency Care
Date____________________________
Client
Name________________________________________________________________________
Address____________________________________________________________________________
City______________________________State___________Zip_______________________________
DOB _________________Age____________
Disability______________________________________
Parent/Guardian
Name_______________________________________________________________
Address if different than
above_________________________________________________________
Phone ______________________________Alternate
Phone_________________________________
Email
address_______________________________________________________________________
Drivers License Number
______________________________________________________________
Medical Insurance
Information/ID#_____________________________________________________________________
Known
Allergies_____________________________________________________________________
Any reactions to prescribed medication, (ex: sun sensitive,
drowsiness, cannot eat certain
foods______________________________________________________________________________
Name of Physician_____________________________Phone_________________________________
I _________________________________hereby give my permission for
emergency care to be sought and/or given to myself or above
named individual in the event that I cannot be contacted or am
incapacitated.
Release of Liability/Consent
I am aware that injury or event death may occur to participants
in this event. Some
of the dangers involved in this activity include terrain
changes, tree location, hill machinery and/or possible physical
exertion. There are
inherent risks involved with any Challenge Mountain activities.
____________________ Initial you have read and understand.
This event involves physical activity and exertion.
I submit that the participant is in sound physical
condition with no health problems that could be aggravated by
participation in this event.
I release and discharge Challenge Mountain and their
agents from all claims for damages arising directly or
indirectly from applicant’s participation in such activity.
___________________________ Initial
I may or may not have inspected the equipment, site, and
facilities.
Nevertheless, I assume all risk associated with this event,
participation in it, including but not limited to the conditions
of the equipment, site(s), facilities, and the unknown ability
of other participants.
___________________________Initial
I give permission for the participants photograph to be used for
media relations, fundraising, and identification of client for
medical purposes. ________________Initial
I understand that I am being allowed a courtesy of borrowing
equipment for use at the facility.
I understand that I must turn this back in to a Challenge
Mountain staff person.
If equipment is not returned I will be charged full
retail price for the equipment.
________________ Initial
Furthermore, Challenge Mountain maintains volunteers of staff
that have received citizen level CPR and first aid training.
There volunteers act solely on their own accord and
Challenge Mountain will not be held liable for their actions.
The acts of volunteers are covered under the theory of
Good Samaritan, which releases them from liability.
Challenge Mountain will maintain infection control, first
aid, and barrier protection.
It is my express intent, by signing this release and
participating in this event, to waive, relinquish, and release
any claims, which I might have against any and all volunteers,
directors, executive directors, officers, agents, and employees
of both Challenge Mountain of Walloon Hills, Inc. and also the
organizations called Challenge Mountain of Walloon Hills, Inc.
I intend this release of liability to be effective
against me, my spouse, my heirs, successors, and assignees.
By signing the Release of Liability, I signify that I have read
and understand it.
I also understand that my participation is dependent upon my
knowing and voluntary execution of this Release of Liability.
Print Name________________________________________________
Signature__________________________________________________
Date______________________________________________________
|