Camp+Permission+Slip

Please print, fill out and sign. Return this by Friday, September 26th. Thank you!

ASSUMPTION OF RISK / REGISTRATION FORM Challenge Course

Camp Whitcomb/Mason

I am aware in signing this document for participation in the Challenge Course experience, that the Challenge Course is a potentially hazardous experience and certain elements of the program can be physically and emotionally demanding. I understand that, although the professional staff will make every reasonable effort to minimize exposure to known risks, not all dangers and hazards can be foreseen (i.e.: cuts, scrapes, bruises, fractures, debilitating injuries, fatalities, etc.) Furthermore, I am aware that certain risks and dangers exist in these activities that are beyond the reasonable control of the Boys & Girls Clubs of Greater Milwaukee Inc. I understand that the Boys & Girls Clubs of Greater Milwaukee Inc. has the right to deny participation and that it is my responsibility as a participant to follow the safety standards, guidelines, and procedures established by the staff/instructors. If I do not understand specific instructions from the staff/instructor at any time, I realize it is my responsibility to ask for clarity and/or assistance.

In signing this document, I authorize the leader of the activities to secure such medical advice and services as deemed necessary for my health and safety and I agree to accept financial responsibility: -Where my health and well-being is involved -Where medical advice has been such that further services are required -Where all reasonable attempts to contact family have failed or where the nature of the emergency does not allow time to make contacts. -Where the benefits of my health insurance plan have been exhausted and additional loss of income and/or medical expenses are incurred.

I understand, assume and accept all dangers, and risks of personal injury and death associated with this course. I waive all claims against the Boys & Girls Clubs of Greater Milwaukee, Inc. staff and assigns, it's officers, shareholders, employees, volunteers, agents and their heirs, executors and assigns, for any incidents that should occur due to my voluntary participation in this experience. Furthermore, I give my consent to the instructors or other medical personnel to treat me in a medical situation. Participation in the Challenge Course is potentially dangerous to individuals who are pregnant and their unborn child. Anyone who is or believes that they may be pregnant should consult with her physician prior to participation. My signature on this document is also intended to bind my successors, heirs, representatives, administrators and assigns.

MEDICAL DISCLOSURE / HEALTH FORM (Please print) Name_ __Address__City/State/Zip_ Phone_ __Is participant 11 yr. or older? YES NO Date of Birth__

__Medical Insurance Policy Name and Number___ __In case of emergency please notify: Name__ Relationship Phone

Participant Signature_ __Date__ _

Parent/Legal Guardian Signature _ Date

1. Do you wear eye-glasses/contacts? Yes_ No _

2. Are you currently taking medication that could impair your ability to participate? Yes*_ No *Please explain:

3. Do you have any allergies that could impair your ability to participate? Yes*_ No_ *Please explain:

4. Do you require special assistance of any type? Yes*_ No_ *Please explain:

5. Have you had a recent injury, illness, or operation? Yes*_ No_
 * Please explain:

6. Do you have diabetes, seizures, frequent fainting/dizziness? Yes*_ No_
 * Please explain:

7. Do you have any neck, back, or shoulder pain or injury? Yes*_ No_
 * Please explain:

8. Do you have a history of heart problems or high blood pressure? Yes*_ No __*If you checked yes, please note the following: Participants with a history of heart problems and/or high blood pressure are at risk while participating on the Challenge Course due the emotional and physical demands involved. Whereas heart attacks and fatalities have occurred in situations where individuals with pre-existing heart/high blood pressure conditions have participated in Ropes and Challenge Course activities, Boys & Girls Clubs of Greater Milwaukee, Inc. can not guarantee your physical safety should you choose to participate. Boys & Girls Clubs of Greater Milwaukee, Inc. requires that all participants answering YES to question #8 acquire a written approval from their physician prior to participation.

For general information regarding pregnancy, please note the following: The activities involved in the Challenge Course participation often involve twisting, turning, lifting, supporting body weights, unexpected physical contact, potential falling from various heights, and waist harness usage. By participating in these activities while pregnant, you will put yourself and your unborn child at risk and in potentially dangerous situations. Should you decide to participate, the Boys & Girls Clubs of Greater Milwaukee, Inc. can not guarantee the safety of you or your unborn child. If you are pregnant and wish to participate, Boys & Girls Clubs of Greater Milwaukee, Inc., requires that you attain a physician's written approval.

I have read the Boys & Girls Clubs of Greater Milwaukee, Inc., "Assumption of Risk/Registration Form, Medical Disclosure/Health Form" and fully understand it without question. The information I provided is accurate to the best of my knowledge.

Participant Signature__ __Date__

Parent/Legal Guardian Signature __Date__