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NORTHWEST COLLEGE- DEPT. OF OUTDOOR EDUCATION

 

Class Informed Consent/Liability Release

 

 

     I am aware and understand that participating in this activity/class involves a potential risk of minor to severe physical injury, paralysis, or death and understand that this activity/class may be physically and/or mentally demanding and potentially dangerous.  Potential hazards include but are not limited to: travel to and from location, environmental conditions/changes, falls, rope burn, water related injury, hitting body part on fixed objects, resulting in soft tissue, musculoskeletal and/or psychological injury, hypothermia, dehydration or other traumatic event. 

     I agree and hereby state that I am solely responsible for my own participation and for my own physical and emotional well-being.  I am aware and understand that all of the program activities are strictly voluntary and it is my own choice to participate in each activity to whatever degree I deem appropriate.  I further state that, in choosing to participate, I am not under the influence of any chemical substance including alcohol. 

     I willing and knowingly assume for myself, my heirs, family members, executors administrators and assign all risk of physical injury and emotional upset which may occur during or after participating in any aspect of this activity/class and hereby agree to hold Northwest College, its employees, instructors, facilitators, and agents harmless for liability arising out of my participation in the program.  This release is specifically intended to release Northwest College, its employees, instructors, facilitators, or agents from claims that their negligence caused the harm, injury or damages alleged to have occurred.

 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's NWC ID Number

Please enter NWC ID number. *
First Participant's Signature*
Participant'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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's NWC ID Number

Please enter NWC ID number. *
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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