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  • Challenge Course FacilitationAgreement to Participate, Including Assumption of Risks and Agreements of Release and Indemnity

  • In consideration of being allowed to participate in this Challenge Course Workshop, facilitated and conducted by Adventure Experiences of Trinity, Texas, I acknowledge and agree as follows:

    The workshop in which I will be participating includes instruction and moderate to strong physical exertion on low and high elements, challenge courses, including a network of cables, ropes, swings and platforms, as high as 50 feet or more off the ground, over and on which I may walk, swing, and otherwise move with or without the assistance of other persons. These activities include exposure to the natural elements, which may include heat, extreme cold and high altitude, snow, sleet and rain; close personal contact, including the possibility of unwelcome touching, and dependence on other participants and staff; incidents may occur in remote places which may be many hours from medical facilities; and incidents may result from the carelessness of other participants and staff; and the failure of equipment. These risks and hazards are inherent in the activities of the workshop and the environment in which it is conducted, and they cannot be eliminated without significantly changing the nature of the activities.

    I understand that these hazards and risks may result in loss or damage to personal property, and emotional and other personal injuries, including falls, abrasions, sprains, breaks, and, in extreme cases, even death.

    I represent that I have no medical or emotional condition which may adversely affect my participation in this workshop, or which may cause me to be a danger to myself or others. I have listed on the Health History Form provided by Adventure Experiences any and all medical conditions which I believe should be brought to the attention of Adventure Experiences. I understand that it is my responsibility, and mine only, to determine my suitability, medical or otherwise, for participation in the workshop.

    Acknowledgment and Assumption of All Risks

    I acknowledge and assume all risks of the workshop, its activities and the environment in which it is conducted, whether or not those risks are inherent, whether or not they are described above.

    Agreements of Release and Indemnity

    I agree to release and hold harmless Adventure Experiences, its shareholders, directors, officers, employees, agents and contractors ("Released Parties") from any and all claims which I now have or may acquire in the future, including claims of negligence but not claims of gross negligence or intentionally wrongful conduct, as a result of or arising from my enrollment or participation in the workshop.

    I further agree to protect and indemnify (that is, defend and pay any judgment and costs, including attorney's fees) Adventure Experiences, and the other released parties from any claim of third parties, including rescuers, other participants in the activities of Adventure Experiences, and members of my family, arising from my enrollment or participation in the workshop.

    Other

    I certify that I am completely healthy (both physically and emotionally) and capable of participating in this Challenge Course Program. I understand that it is solely my responsibility to determine whether there is any medical reason that I should not participate in the program. I also understand that Adventure Experiences and all of its representatives are in no position to determine whether I'm capable to participate in this program. My participation in this program is based on my decision to do so.

    I agree to reimburse or pay any and all costs of Adventure Experiences or any other released party associated with defending a claim brought by me or by anyone on my behalf, to the extent that claim is dismissed or otherwise found to be without merit.

    In the event of a dispute between me and Adventure Experiences or any released party, I agree to engage in good faith efforts to mediate that dispute. Unless otherwise agreed in writing, any mediation or suit may be conducted or filed only in Trinity County, Texas, and the laws of the State of Texas will apply to any such dispute, excepting only the laws of the State of Texas which may apply the laws of another jurisdiction.

    I authorize Adventure Experiences to provide or obtain medical care for me in the event of an incident requiring medical attention, and I further authorize Adventure Experiences to exchange with any third-party medical care giver such information regarding my medical history or condition as may be deemed important to either of them.

    I agree that I will not consume or be under the influence of any chemical substance, including alcohol, during the workshop. I understand further that the activity and all aspects of it are purely voluntary and I may choose not to participate. I agree that I will follow all safety instructions. I agree to allow Adventure Experiences to use photographic or other images of me for marketing or any other purpose deemed reasonable by Adventure Experiences.

    Should any part of this agreement be deemed not enforceable by a Court of competent authority, the remainder of the agreement shall nevertheless remain in full force and effect.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Health Statement

  • The proposed activity provided by Adventure Experiences requires participation in physical exercises which are, by their nature, physically demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any heart or any other diseases. Therefore, all participants must be free of medical or physical conditions which might create undue risks to themselves or any others who depend on them. Good physical condition will increase your enjoyment of the outdoor activities. If there is any doubt about your ability to safely participate in this experience, you should have a physical examination.
  • BIRTH DATE*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • DATE OF LAST PHYSICAL EXAM
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • HEALTH HISTORY: (Circle the appropriate answers and describe any YES answers with corresponding dates where applicable.)

  • HAVE YOU OR DO YOU CURRENTLY HAVE ANY HEART PROBLEMS? (NOTE: If you have had any heart related problems you will need to have a release form from a physician in order to go through a high elements training.)*
  • DO YOU FREQUENTLY SUFFER FROM PAINS IN YOUR CHEST?*
  • DO YOU OFTEN FEEL FAINT OR HAVE SPELLS OF SEVERE DIZZINESS?*
  • HAS YOUR DOCTOR EVER TOLD YOU THAT YOU HAVE HIGH BLOOD PRESSURE?*
  • ARE YOU A SMOKER?*
  • DO YOU HAVE ARTHRITIS, JOINT, OR BACK PROBLEMS THAT MIGHT BE AGGRAVATED BY EXERCISE?*
  • HAVE YOU HAD ANY OPERATIONS OR SERIOUS INJURIES?*
  • DO YOU HAVE DISABILITIES OR CHRONIC RECURRING ILLNESS?*
  • ARE THERE ANY ACTIVITIES TO BE LIMITED/DISCOURAGED BY PHYSICIANS ADVICE?*
  • ARE YOU ALLERGIC TO ANY MEDICINES, INSECTS, OR POLLEN?*
  • DO YOU HAVE EPILEPSY?*
  • DO YOU HAVE DIABETES?*
  • DO YOU HAVE ANY PRESCRIBED MEAL PLAN OR DIETARY RESTRICTIONS?*
  • ARE YOU CURRENTLY SICK AND/OR USING A MEDICATION THAT'S NOT LISTED ABOVE?*
  • DO YOU CARRY FAMILY MEDICAL/HOSPITAL INSURANCE?*

  • Representation and Emergency Authorization

  • This health history is correct so far as I know, and I believe that my health is satisfactory to participate in challenge course activities. I hereby give permission to the medical personnel selected by Adventure Experiences to order injection and/or anesthesia and/or surgery for me. Such authorization for emergency treatment shall include, but not be limited to, charges incurred for the providing of aid and arranging evacuation if Adventure Experiences or its agents, determine that such evacuation is necessary or desirable. I further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned. I also understand and agree by any restrictions placed on my activities.
  • DATE*
     - -
    2 digit month, 2 digit day, 4 digit year
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