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Northwest College- Dept. of Outdoor Eucation

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.

I Agree

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & number. *
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*
Medical Information

Answers to the following questions must be complete.

Please print or type all information clearly.

This medical form is intended to provide the Northwest College (NWC) course instructor, college, and other medical personnel of any condition that may affect your participation in the activity/course/ program/trip/class, or information needed in the assessment and treatment of medical or physical injury.  As a participant, it is your responsibility to truthfully complete this medical form, and inform your instructor of any pre-existing medical or physical limitation, medications taken, or other pertinent information.


Name of group are are participating with: *

Date(s) of course you are participating in: *

Your Full Name: *

Home Phone Number: *

Cell Phone Number:

Birth Date: *
Sex: *
Male
Female
General Medical History-
Respiratory Problems? Asthma?*
No
Yes
Gastrointestinal disturbances?*
No
Yes
Diabetes*
No
Yes
Bleeding or blood disorders?*
No
Yes
Neurological disorders?*
No
Yes
Seizures?*
No
Yes
Past injury/surgery/joint problems?*
No
Yes
Any dietary considerations*
No
Yes
Other disease or recent illness*
No
Yes

If you answered yes to any of the questions above, please explain your answer here. If you answered no to al of the questions, please type "N/A" *
Allergies
Do you have any allergies? If you checked yes, please detail in the space below.*
No
Yes

Medications:

Food:

Other:
Medications

Please list all medications you are currently taking and why. If you are not taking any medications, please type "N/A" *
Muscle/Skeletal Injuries

Do you currently have, or do you have a history of:

Knee, hip, ankle, shoulder, arm, or back injuries (including sprains/strains) and/or operations?*
No
Yes

Please explain your answer. If you checked no, please type "None". *
Smoke?*
No
Yes

packs per day?

If you answered yes to any of the above, please explain here. If you answered no to all the questions, please type "N/A" *
Cardiac Screening
Chronic or unexplained chest pain?*
No
Yes
Family history of heat disease?*
No
Yes
High blood pressure?*
No
Yes
Current/prior cardiovascular disease?*
No
Yes
Additional Information

Please include any special needs, issues, or concerns that we need to know about you such as pertinent medications like asthma inhaler, epi-pen locations or things not asked on this course. If there are none, please type "none". *
Additional Information

VII. This medical form provides us with information required for course safety and emergency situations.  By requesting this medical history, we do not imply that we have the expertise to assess your physical condition, or your ability to participate safely in an activity/course/program/trip/class, referred to from here on as "course". This determination of ability to participate must be made by the participant in concert with his/her physician. NWC courses demand sometimes strenuous exercise.  Although safety is our first priority and we are trained to provide first aid in case of incident, your participation in this NWC course is strictly voluntary and indicates your acknowledgement and the assumption of inherent risk associated with potentially being far from professional medical facilities.  If you have any questions, please contact the Course Instructor, Outdoor Education Program Coordinator or Life & Health Sciences Division Chair for further details.

VIII. Consent is hereby given to attend an NWC "course" and permission given for emergency transportation, anesthesia, operation, hospitalization, or other treatment which might become necessary.  The information provided above is a complete and accurate statement of the physical factors which may affect me/my child's participation in an NWC activity/course/program/trip/class.  I realize that failure to disclose such information could result in harm to myself and my fellow participants, and I agree to indemnify and hold harmless Northwest College and its assigns if all relevant information is not disclosed.  I also agree to notify Northwest College should there be a change in my health prior to the "course".  Emergency transportation and treatment shall be the participants/guardians responsibility for payment.  The NWC Instructor, Facilitator, Outdoor Education Program Director, or other NWC College Employee associated with the "course", has the right to stop or refuse your participation in the "course" if they feel it is a safety concern to yourself or your group members.

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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Please Enter your NWC ID number. *

Enter the class information for the class you are signing this waiver for. EXAMPLE: "SP18 OEAC 1175". That equals: semester, year, course designator & 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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