Participant Acknowledgment of Risks
In consideration of the services of Gasper River Catholic Retreat Center, their facilities, employees, the Diocese of Owensboro in Kentucky and all other persons or entities associated with Gasper River Catholic Retreat Center (hereafter referred to as “GRCRC”), I agree as follows:
I understand that this event may include the opportunity for physical activities which may include, but is not limited to hiking, teambuilding, environmental education, folkdancing, swimming, fishing, river activities, and campfires, which involve a variety of activities that often include, but is not limited to, warm-ups, games, group initiative problems, and low ropes course elements. Although GRCRC has taken reasonable steps to provide me with appropriate equipment and skilled facilitators so I can enjoy activities for which I may not be skilled, GRCRC has informed me that these activities are not without risks. The same elements/activities that contribute to the unique character of these activities can be causes of accidental injury, illness, or in extreme cases, permanent trauma or death, or loss or damage to my personal property. GRCRC does not want to frighten me or reduce my enthusiasm for the activity, but believes it is important for me to know in advance what to expect and to be informed of the inherent risks.
I am aware that participation in activities entails risk of injury or death to any participant. I understand the description of these inherent risks is not complete and that other unknown or unanticipated inherent risks may result in injury or death. I agree to assume and accept full responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in these activities 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. I acknowledge that engaging in these activities may require a degree of skill and knowledge different than other activities and that I have responsibilities as a participant. I acknowledge that GRCRC staff has been and will be available to more fully explain to me the nature and physical demands of each activity, and the inherent risks, hazards, and dangers associated with these activities.
I certify that I am fully capable of participating in these activities. Therefore, I assume and accept full responsibility for myself, including all minor children in my care, custody, and control, for bodily injury, death or loss of personal property, and expenses, as a result of those inherent risks and dangers identified herein and those inherent risks and dangers not specifically identified, and as a result of my negligence in participating in this activity. I have clearly read, clearly understand, and fully accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon myself, my heirs, assigns, personal representative, and estate for all members of my family, including minor children.
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Participant Signature Date
________________________________________________ _______________________
Parent/Guardian Signature (if participant is
under 18 years old) Date
Participant must correctly fill out all of
the information on the backside of this form.
Participant Information
1. Name: ______________________________________________________________________
2. Address: ____________________________________________________________________
3. City:
4. Phone: Home _________________ Work __________________ Cell ___________________
5. Person to notify in case of accident or emergency:
Name: _______________________________ Phone #: _______________________________
6. Do you have health/accident insurance? Yes _____ No _____
If Yes, name of company: ______________________________________________________
Insurance Company address: ____________________________________________________
Policy or Certificate number: ____________________________________________________
7. Do you have any conditions that would limit your involvement in physical activities?
If yes, please explain: __________________________________________________________
______________________________________________________________________________
8. Are you currently under a physician’s care? If yes, please explain: ______________________
______________________________________________________________________________
9. Are you currently taking any medications, prescribed or otherwise? If yes, please state what
you are taking and for what condition: ____________________________________________
______________________________________________________________________________
10. Do you have any allergies, reactions to medications, or any other medical limitations?
If yes, identify and explain: ____________________________________________________
______________________________________________________________________________
11. Do you take any medication for bee stings or other allergies? ______ If yes, bring it with you
12. Do you have heart murmurs, episodes of irregular heartbeat, shortness of breath or chest pain
upon exertion? If so, describe symptoms and physician’s diagnosis: ___________________
_____________________________________________________________________________
13. Do you have asthma? If so, has the condition been stable for the past year? ______________
_____________________________________________________________________________
14. Do you have problems with your neck, back, arms, ankles, or knees that limit your activities?
Describe symptoms and limitations: _____________________________________________
_____________________________________________________________________________
15. Do you suffer from severe headaches, dizziness, or fainting? Describe: ________________
_____________________________________________________________________________
16. For females only: Are you pregnant, or is there a chance that you may be pregnant? _______