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The Synergy Project LLC

427 East Main Street

PO Box 2143

Chattanooga, TN 37409

Please note: This is NOT the GYM waiver.

For the gym waiver go to synergyclimbingandninja.com and click on the waiver link on the home page or under visitor info.

This form is only for those participants taking trips outdoors or off-site. All medical information is considered private and confidential and is not shared with anyone other than as needed for the safety of participants by trip managers.

If you are an adult parent or legal guardian who is NOT participating, but need to fill out the form for a minor particpant, please simply select "Minor(s)" below.

If you are an adult participant, please select "Adult" or, if participating and adding minors too, select "Adult and Minor(s)."

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information about future trips, camps or clinics.
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*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information
Does this participant have any medical condition that could affect participant's safety or health when undergoing this very strenuous activity--such as a heart condition, or problems with balance, dizziness or seizures, or ANY other concerns?*
No
Yes

If "Yes" please explain: 

Is this participant prone to muscle or skeletal injuries or have a history of such injuries?*
No
Yes

If "Yes" please explain: 

Is this participant taking any medications or drugs?*
No
Yes

If "Yes" please list: 

Does this participant suffer severely from any allergies, such as to food, medications, insect stings, or anything else?*
No
Yes

If "Yes" please explain:

Regarding the previous question, does this participant carry an inhaler or medication or an Epipen, Auvi-q or similar to alleviate symptoms if necessary?*
NOT RELEVANT -- Participant does not suffer significantly from any such conditions.
Yes, and the participant will have the necessary medication, inhaler or Epipen or similar readily accessible at all times.
No, the participant cannot eat certain foods or participate in some activities due to the risk.
Does this participant suffer from asthma or other respiratory condition?*
No
Yes

If "Yes" please state:

Regarding the previous question: Can this participant adequately control his/her condition during or after athletic activity by use of an inhaler or medication?*
NOT RELEVANT -- participant does not suffer from asthma or other respiratory condition.
Yes, and the participant will have the appropriate medication and/or inhaler easily accessible at all times.
No. This participant will not engage in any climbing or other strenuous activity.
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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