Ropes Course

HILLTOP CAMP

Challenge (Ropes) Course Program

CONSENT TO RELEASE FORM

A challenge course (or “ropes course”) is a series of challenges designed to improve the performance and cohesiveness of a group or team. All of the challenging activities are conducted within a safe, fun, and supportive atmosphere. The challenge course program offers participants an opportunity for team building, establishing trust, encouraging cooperation, and emphasizing communication, while becoming effective members of group problem solving. The program capitalizes on the experiential learning from fun games and enjoyable initiative problems. Therefore the personal and group experiences gained through participation may be used as a metaphor for many personal, spiritual, and professional challenges of everyday life. Participation in the individual elements of the challenge course program is voluntary, but all members of the participating team may be required to attend all or certain portions of the program to offer necessary encouragement and support to those who choose to participate. All members are still required to sign this form.

Hold Harmless Agreement

1. In consideration for participating in the Hilltop Camp and other valuable consideration. I hereby RELEASE, WAIVE, DISCHARGE AND CONVENANT NOT TO SUE Hilltop Camp, the Board of Directors, the State of Texas, their officers, servants, agents, and employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions, causes of action whatsoever arising out of or related to belonging to me. Whether causes by the negligence of the releasees, or otherwise, while participating in such activity, or while in on or upon the premises where the activity is being conducted or in transportation to and from said premises.

2. To the best of my knowledge, I can fully participate in this activity. I am fully aware of risks and hazards connected with the activity, including but not limited to the risks as notes herein, and I hereby elect to voluntarily participate in said activity, and to enter the above names premises and engage in such activity knowing that the activity may be hazardous to me and my property. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me or any loss or damage to property owned by me, as a result of being engaged in such an activity, whether caused by the negligence of release or otherwise.

3. I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs, including court costs and attorney’s fees, that may incur due to my participation in said activity, whether caused by the negligence of releases of releasees or otherwise.

4. I understand that Hilltop Camp will not be responsible for any medical costs associated with an injury, other than minor injuries, I may sustain.

5. I further agree to become familiar with the rules and regulations of Hilltop Camp concerning camper/participant conduct and not to violate said rules of any directive or instruction made by the person or persons in charge of said activity and that I will further assume the complete risk of any activity done in violation of any rule or directive or instruction.

Health, Physical Fitness and Risk

There are risks involved when participating in activities offered on the Hilltop Camp Challenge Course. The proposed activity provided by the Hilltop Camp Challenge Course requires participation in physical exercises which are, by their nature, physically demanding and may be performed from ground level and up to heights of 50 feet. Many of the activities will challenge you, and cause surges in blood pressure and respiration and pulse rates. It is imperative that you are free of any heart-related or other diseases. Therefore, all participants must be free of medical, psychological or physical conditions, which might create undue risks to themselves or any others that depend on them. I also state that I am not under, and will not be under the influence of any chemical substance including alcohol during my participation of this program. 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 medical physical examination. The individual is completely responsible for his/her own safety and health.

REPRESENTATION AND EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel to provide necessary medical services including but not limited to, injection and/or anesthesia and/or surgery for me/my child as named below. I further agree to assume responsibility for the costs of any specialized evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned.

I/My child have reviewed the above information and am aware of the risks involved in participating in the Hilltop Camp Challenge Course activities and the possible injuries which may occur. I/My child freely and voluntarily agrees to participate in the activity listed herein.

In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign voluntarily as my own free act and deed; no oral representations, statements of inducements, apart from the foregoing written agreement, have been made; I am fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same.

Participant’s Name (Please Print) Participant’s Signature*

If participant is under 18, the parent/guardian must sign below

Date Release Signed Parent’s or Guardian’s Signature

HILLTOP CAMP

HEALTH STATEMENT

The proposed activity provided by the Hilltop Camp Challenge Course 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 related or other diseases. Therefore, all participants must be free of medical or physical conditions that might create undue risk 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 the experience, you should have a physical examination.

Participant’s Name:_____________________________________________________________________________ DOB:_______________________

Parent/Guardian’s Name: Phone #:__________________________

HEALTH HISTORY: (Circle the appropriate answer and describe any YES answers)

Have you had or do you currently have any heart problems? (provide dates)	YES	NO

Do you frequently suffer from pains in your chest?	YES	NO
Do you often feel faint or have spells of severe dizziness?	YES	NO
Has a doctor ever told you that you have high blood pressure?	YES	NO
(Note: If you have had any heart related problems or answered YES to any of the above questions you will need to have a release from a physician in order to do high elements.)
Are you a smoker?	YES	NO
Do you have arthritis, joint or back problems that might be aggravated by exercise?	YES	NO
Have you had any operations or serious injuries? (dates)	YES	NO

Do you have any disabilities or chronic recurring illnesses or communicable diseases?	YES	NO

Are there any activities to be limited/discouraged by physician’s advice?	YES	NO

Do you have Epilepsy?	YES	NO
Do you have Diabetes?	YES	NO
Are you allergic to any medicines, insects or pollen? If so, which ones?	YES	NO

Do you have asthma?	YES	NO
Do you have any prescribed meal plan or dietary restrictions?	YES	NO

Are you currently sick and/or using a medication that’s not listed above?	YES	NO


Do you carry family medical/hospital insurance?	YES	NO
Carrier:________________________________ Policy #:_____________________________
Suggestions or health related information for Hilltop Camp Challenge Course: ___________________________________________________________________________
General Health Statement:_______________________________________________________

Presentation 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.

Permission to Provide Necessary Treatment or Emergency Care

I hereby give permission to the medical personnel selected by the challenge course staff to order X-rays, routine tests, treatment to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the challenge course staff to secure and administer treatment, including hospitalization, for the person named above.

Signature of Parent/Guardian: Date:

(if participant is under 18)

Signature of Participant: Date:

Witness: Date:

This person verifies that the signatures above were obtained from the persons named.

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