UNDERSTANDING OF RISK

Background Information:

The activities are designed to physically and mentally challenge the participants. Physically, the activities may involve stretching, balance, strength, and cardiovascular work. Participants will be asked to take physical and emotional risks, but physical prowess is not necessary to successfully complete the challenges.

The challenge course consists of cables, ropes, poles and tires. The course is constructed in such a manner as to create a challenging and unique series of group and individual obstacles.

The challenge activities are used as a catalyst for personal, group, and educational growth. The activities emphasize the importance of trust, teamwork, group cooperation and support, going beyond self-perceived limits and the positive utilization of stress.

To The Participants:

I, ______________________________________________, in consideration for being permitted to participate in _________________________________________(group name) Cañon City Area Metropolitan Recreation and Park District Program understand that even under the safest conditions, these activities have a number of inherent risks and hazards.

I further understand that the challenge activities may be physically, mentally; and/or emotionally demanding. I understand that I should be free of any mental, medical, and/or physical conditions that may create undue risk to myself or others who may depend on me.

I agree to comply with the safety rules and regulations set forth by the Challenge by Choice Ropes Course, Climbing, and Outdoor program staff. I also agree to inform them of situation(s) that appear to me to be a danger to myself or my co-participants.

These situations may include:

· Broken, equipment

· Feeling sick or very tired

· Having extreme difficulty performing a skill

I also agree that my participation in the Cañon City Recreation and Park District Challenge by Choice Ropes Course, Climbing, and Outdoor Program is voluntary on my part. I have carefully read this agreement and understand its content.

________________________________________ ____________________________________

Signature of Participant Date

__________________________________________________________

(Signature of Parent, if participant is under 18 years of age)

GROUP NAME__________________________________ ____ COURSE DATE ________________________

CONFIDENTIAL MEDICAL HISTORY FORM

DIRECTIONS: Because of the physical nature of the adventure activities, it is important of the leadership staff to be informed of any and all medical conditions of the participants.

Please fully complete an sign this form.

GENERAL INFORMATION

Name _______________________________________Date _________________________________________

Address ___________________________ City ___________ State _______________ Zip Code ____________

Telephone _______________________ Date of Birth _____________________________ Age _____________

Male _______ Female ________ Height ______________ Weight _____________ Grade Level ____________

Name of Family Physician ____________________________________________________________________

Physician’s Address & Phone _________________________________________________________________

Person To Be Notified in Case of Emergency ____________________________________________________

Address of Emergency _______________________________________________________________________

City ______________________ State ___________________ Zip __________ Telephone ________________

Relationship _______________________________________________________________________________

MEDICAL HISTORY:

Please describe current condition/treatment where applicable.

ALLERGIES (EG. INSECT BITES, MEDICATIONS, FOOD, ETC._________________________________ __________________________________________________________________________________________

CONDITIONS REQUIRING REGULAR MEDICATIONS (EG. DIABETES, EPILEPSY) ________________ __________________________________________________________________________________________

RECENT INJURIES, ILLNESSES, OPERATIONS________________________________________________ __________________________________________________________________________________________

IMPAIRMENT OF SIGHT, HEARING, SPEECH _________________________________________________

__________________________________________________________________________________________

HERNIAS, CONCUSSIONS, DISLOCATIONS, SPRAINS, STRAINS, FRACTURES __________________________________________________________________________________________

RECURRENT DIZZINESS OR HEADACHES ___________________________________________________

CURRENT INFECTIONS, VIRUSES __________________________________________________________

MUSCLE, JOINT, BACK PAIN, BURSITIS _____________________________________________________

CHEST PAINS, SHORTNESS OF BREATH, HEART PALPITATIONS, HEART DISEASE, HEART MURMURS, HIGH BLOOD PRESSURE _______________________________________________________ _________________________________________________________________________________________

GASTROINTESTINAL PROBLEMS (EG. ABDOMINAL PAINS, DIARRHEA) OR OTHER PHYSICAL DIFFICULTIES OR CHRONIC CONDITIONS ___________________________________________________

__________________________________________________________________________________________

EMOTIONAL OR BEHAVIORAL PROBLEMS (EG. PHOBIAS, DIAGNOSED DISORDERS) ___________

__________________________________________________________________________________________

CIGARETTE, DRUG, ALCOHOL DEPENDENCE _______________________________________________

__________________________________________________________________________________________

I fully understand the physical nature of the Adventure Challenge Program activities. I assume full responsibility for my health being such that the activities will in no way aggravate any present conditions. If in doubt, I will seek medical advice.

Signature ____________________________________ Date ______________________________

_______________________________________

(Signature of parent, if participant is under 18 years of age)

Please check if you would like to be on our mailing list ___________________