Mid-South Youth Camp Ropes Course
Participant Information and Release of Liability

Disclosure: Ropes Course programs involve a variety of activities that often include warm-ups, games, group initiative problems, high and low ropes course elements, and other rigorous physical adventure activities. The level of participation in a ropes course activity is at all times completely voluntary and up to the individual’s choice. Yet, there is a risk which must be assumed by each participant, that he or she may suffer an emotional or physical injury or disability. Policy for participation in all ropes course programs requires that every participant have health/accident insurance coverage. In addition, certain health/medical information must be made known to the instructor(s) conducting programs so they will be prepared to respond appropriately if the need arises. This information will be read by your ropes course facilitators ONLY and kept in strict confidence.

Name  
Street  
City  
State  
Zip  
Participant Home Phone    
Age Now  
Height  
Weight  
Gender  

Emergency Contact Information
Emergency Contact  
Full Address  
Home Phone    
Work Phone    
Relationship to participant  
Do you have health/accident insurance?
Name of Company  
Are you currently taking medication (prescribed or otherwise)
If yes, state what you are taking and what condition it is for:
 
Do you have any allergies, reations to wasp/bee stings, foods or medications?

If yes, identify and explain:

Do you have any medical limitations that might affect your safe participation in our program? If yes, please explain.

Release of Liability I understand that parts of the ropes course program may be physically/emotionally demanding. I affirm that my health is good and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in ropes course activities. I understand that the level of participation in ropes course activities is at all times completely voluntary and up to the individual’s choice. Also, I recognize the inherent risk of injury or disability in ropes course activities. I release Mid-South Youth Camp, Freed-Hardeman University, and its staff members and Board of Directors from all liability for any injuries or damages from participation in ropes course activities.
 
Date  
Participant's Signature
Parent or Guardian's Signature (if participant is under 18 years)