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Youth Climbing Wall Medical Registration & Waiver 

I, hereby declare that I am the parent or legal guardian of the above participant, and consent that he/she may participate in activities at Hoodoo Adventure Company. I certify that the above information is true and accurate, and agree to advise Hoodoo Adventure Company, in writing, of any change to the medical condition of the person listed above. I understand that unless Hoodoo Adventure Company hears from me otherwise, they will assume all medical information is unchanged from the date of this agreement.


 

Hoodoo Adventures' staff, and occasionally local media, take a variety of photographs and/or video of camp activities. These photos/videos may be posted in the camp's online photo gallery, Facebook & Instagram page, or used for promotional purposes (e.g. website, brochures, posters, camp fair display, etc), but NO names will be used.

I give Hoodoo Adventures Permission to Use Photos/Video of my child to illustrate and promote the camp experience, Hoodoo Adventures, and its camp programs 


Waiver & Release of Liability

Amateur Athletic Waiver and Release of Liability
In consideration of being allowed to participate in any way in the Hoodoo Adventure Company athletic sports program, related events and activities, the undersigned acknowledges, appreciates and agrees that:

1. The risk of injury from the activities involved in this program is significant, including potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and, 

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES, or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, 

4. I for myself and on the behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS, Hoodoo Adventure Company, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors or premises used to conduct the events (“Releasees”), WITH RESPECT TO ANY INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY NEGLEGENCE OF THE RELEASEES OR OTHERWISE. 

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHT BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 

 

I Agree

FOR PARTICIPANTS UNDER THE AGE OF MAJORITY (UNDER AGE OF 18 AT THE TIME OF REGISTRATION)
This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above.

April 26, 2024

Please select Minor(s). Once you do that click the number of children you have. Than click continue and fill in the Youth Registration & Medical Form.
AdultMinor
Continue
First Youth's Name

First Name*

Middle Name

Last Name*

Phone*
First Youth's Age Acknowledgment*
First Youth's Date of Birth*
I certify that I am 18 years of age or older
First Youth's Signature*
Youth's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Custody:
In the past year have there been any changes in the home or family?*
Both Parents
Joint Custody
Mother
Father
Step Parent
Foster Parent
Other

If other, please specify:
Marital Status of Parent/Guardian*
Married
Separated
Divorced
Single
Widowed
Common Law
Other

If other, please specify:
Doctor's Information

Doctors Name:

Doctors Phone Number:
Medical Needs & Information:
Does this child have life threatening allergies?*
No
Yes

If yes, please complete a Anaphylaxis form. Once you complete the form it will be saved in our system. see this link: https://waiver.smartwaiver.com/v/hoodooanaphylaxis/
Does your child have any non-life threatening allergies?*
No
Yes

If yes, please specify
Does this child have asthma?*
No
Yes
If yes, how severe?*
Mild
Moderate
Severe
Activity Induced

Please detail medications and treatment plan:

**If your child requires an epi-pen or inhaler please leave them with the instructor and discuss this plan with your child and the instructor**

Health History
Has your child experienced, currently experiencing, taking medication, or seeking treatment for any of the following:
Back/Neck Pain or Injury
Behavioral Issues
Blackout/Fainting
Bleeding Disorders
Chest Pains
Chrons/Colitis/IBS
Concussions
Developmental or Learning Disabilities
Diabetes
Epilepsy/Seizures
Fetal Alcohol Syndrome
Headaches/Migraines
Heart/Kidney/Organ Conditions
Motion Sickness
Nosebleeds
Sprains/Strains/Fractures
Other (see below question)
My child is not experiencing, taking medication, or seeking any treatment of any of the above conditions.

If Other, please explain:
Does this child have a current tetanus immunization?:*
No
Yes
Does this child have any limitations to participation? (Physical, emotional, social or otherwise that will affect their enjoyment of the program)*
No
Yes

If yes, please explain:
Does your child have Social Disorders we should be aware of?*
No
Yes

If yes, please explain anything we should be aware of to help ensure your Child's best chance at success.
May the following over-the-counter medications be administered to your child if deemed necessary by Wilderness First Responder certified Instructors?
Acetaminophen (Tylenol)
Antacids
Antihistamines (Benadryl)
Gravol
Ibuprofen (Advil)
None of the above
All of the above
Other (see next question)

If other please specify, what medication are ok.
Emotional Considerations
In the past year have there been any changes in the home or family?
Birth
Marriage
Separation
Divorce
Passing
Other
None
Does your child make friends easily with..
Younger Kids
Older Kids
Same Age
Adults
Other

If other, please specify. ie everyone: younger kids, same age kids, older kids, and adults.
Is your child...
Eager to Attend
Nervous or Anxious to Attend
Urged by Parents or Guardian to Attend
Does this child have any other emotional needs or considerations?*
No
Yes

If yes, please describe:
Health History Information and Treatment Notes:

Please describe any treatment, medication dosage & timing, or additional notes with regards to your child's health history:
FOR PARTICIPANTS UNDER THE AGE OF MAJORITY (UNDER AGE OF 18 AT THE TIME OF REGISTRATION)
This is to certify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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