Loading...

PIVOT ADVENTURE, NONPROFIT
ACKNOWLEDGMENT OF RISK, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT
READ CAREFULLY BEFORE SIGNING – THIS LIMITS PIVOT’S LIABILITY

 

 

I, on behalf of myself and my child (collectively referred to as “I”, “my”, or “me”) have voluntarily chosen to participate in recreational activities, including but not limited to indoor  and outdoor rock climbing, ropes course activities, hiking, snowshoeing, mountain biking, cross-country and downhill skiing, snowboarding, and travel associated with these activities (collectively, “the Activities”). I understand that participation in the Activities poses inherent and other risks of INJURY and DEATH. The risks associated with the Activities include, but are not limited to, falling; landing on or striking padded or unpadded surfaces; being injured by falling objects or participants; being injured by the actions or inactions of other participants, including but not limited to other participants’ failure to belay properly; movement of climbing holds; equipment failures of any kind; naturally occurring hazards and dangers of all kinds; steep and uneven terrain and trail conditions including snow (surface and subsurface conditions), ice, rocks, dirt, mud, sand, vegetation, and cliffs; hazards associated with changes in weather, temperature, and lighting conditions; and other rugged terrain conditions. The risks also include hazards and dangers associated with the use of manmade structures, vehicles, materials, and equipment, including misuse, defect, failure, or inadequacy of equipment.  Other risks include those associated with the use of facilities, including indoor climbing facilities; ropes course facilities; ski resorts including chairlifts, surface lifts, and other conveyances; and participating in instruction and/or special events (collectively, “use of the facilities”).  Despite these risks and all other risks, and TO THE FULLEST EXTENT ALLOWED BY LAW, I ACKNOWLEDGE AND AGREE TO EXPRESSLY ASSUME ALL RISKS OF INJURY OR DEATH that might be associated with or arise out of my participation in the Activities or use of the facilities.

I UNDERSTAND THAT CANYONS SCHOOL DISTRICT DOES NOT ENDORSE, RECOMMEND, OR SPONSOR PIVOT.

TRANSPORTATION (PICK-UP AND DROP-OFF) is provided to and from specific school locations. I understand that I must be on time for my student's pickup. I understand Pivot Adventure has multiple drop-off locations to make and an adult will not be available to wait with students at each school. In the event that my child does not check in for an outing, I consent to messages being left at the following phone number. Pivot Adventure will not be responsible for a student that has not checked in for an activity by the time the van is scheduled to depart. If a student requires an authorized adult to pick them up, the adult must be on time. 

In consideration for being permitted to participate in the Activities and engage in use of the facilities, I AGREE TO RELEASE FROM ANY LEGAL LIABILITY AND AGREE NEVER TO SUE Pivot Adventure, Nonprofit Corp. and all of its successors, heirs, assigns, directors, officers, partners, investors, shareholders, members, agents, employees, owners, volunteers, facility landowners, parent and subsidiary companies, and affiliated companies (collectively herein, “Pivot”) for injury or death resulting from my participation in the Activities or use of the facilities, regardless of the cause, including the alleged NEGLIGENCE of Pivot. I further AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS Pivot for any claims, lawsuits, damages, attorney fees, costs or judgments arising out of my participation in the Activities or use of the facilities.

I UNDERSTAND THIS IS A RELEASE OF LIABILITY that will apply whenever I or my child participate in the Activities or engage in use of the facilities with or associated with Pivot. I understand that this RELEASE OF LIABILITY will prevent me, my child, and our representatives and heirs from filing suit or making any claim for damages in the event of injury or death from my or my child’s participation in the Activities or use of the facilities.  Additionally, in the event I file or my child or any legal representative files a claim or a lawsuit arising out of my or my child’s participation in the Activities or the use of the facilities, I AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS Pivot for any damages, attorney’s fees, or costs arising out of such a claim or a lawsuit. With a full understanding of this agreement, I enter into it freely and voluntarily and agree that it is binding upon me, my child, our heirs, assigns and legal representatives.

I UNDERSTAND THAT PARTICIPANTS IN PIVOT ADVENTURE ACTIVITIES MUST HAVE MEDICAL INSURANCE. I confirm that I and/or my child is covered by medical insurance and that if that status changes I will notify Pivot Adventure immediately and cease and/or have my child cease participating in Activities until coverage is restored. I understand that I alone am responsible to decide whether I and/or my child should engage in the Activities. I confirm that the participant is physically and mentally capable of participating in the Activities, and I understand that if my or my child’s mental or physical condition changes after the execution of this agreement such that I, he or she is not capable of participating in the Activities, I am responsible to cease and/or have my child cease participating.

I acknowledge that Pivot’s representatives and/or other participants or spectators may photograph or videotape the Activities and facilities, including my or my child’s participation therein.  I agree that Pivot may use these recordings in any way, including but not limited to for marketing purposes and as evidence, without compensation or restriction. I understand and agree that this agreement is severable and that if any clause is found to be invalid, the balance of the contract will remain in effect and will be valid and enforceable. 

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

First Name*

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

Parent or guardian name *

Parent or guardian's phone number *
Which school will your student be attending this fall? *
What are the participant's preferred pronouns?

We will use the following sizes to help outfit the participants with gear such as harnesses, climbing shoes, snow shoes, overboots, skis, ski poles etc. Size can be approximate.

Does your child wear men's or women's shoe sizes?*

Shoe Size *

Weight *

Height *
Biking Ability: Our program is a beginner mountain biking course, however, it is strongly recommended that your child be comfortable on a bike before joining this course. Note that only Mount Jordan Middle School will be mountain biking. If the participant is from another school please choose "Not Applicable".*
What kinds of allergies does the participant have?
Animals
Food
Medications
Plants
Pollens
Stinging Insects
Other
None

Please describe the participant's allergies. Include the severity of the reaction and any medications used or carried.

Does the participant have any medical conditions we should be aware of such as asthma, high blood pressure, or a tendency to overheat?

What medications is the participant currently taking (including inhalers)?
Check any personal medical or mental health history for the participant.
ADHD/ADD
Anxiety
Autism Spectrum
Behavioral Addictions
Bipolar
Depression
Domestic Violence
Drug or alcohol use/addiction
Jail time/detention center
Learning disabilities
OCD
ODD
Panic Attacks
PTSD
Schizophrenia
Self Harm
Suicide attempt
Suicide Ideation (suicidal thoughts)

Comments for checked items

Does the participant have any physical/mental/emotional challenges that may require special accommodations? If so, please explain.
Has your child ever had any physical confrontations at home or school?*
No
Yes

If yes, please describe the situation and any calming skills your child uses.

Please describe any major events your child has struggled with and when it occurred (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.).

What are your goals for the course?

Personal medical insurance is required for the participant throughout the program.

Personal medical insurance is required for the participant throughout the program. *
I confirm that the participant is covered by active medical insurance and I will notify Pivot Adventure immediately if coverage is lost.
The participant is not currently covered by medical insurance.
I do not know

Primary Insurance Company *

Insurance Policy Holder's Name *

Relationship to Student *

Policy Holder's Phone Number *
First Participant's Signature*
Parent or Guardian's Email Address

Email*

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


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*

Last Name*

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

Parent or guardian name *

Parent or guardian's phone number *
Which school will your student be attending this fall? *
What are the participant's preferred pronouns?

We will use the following sizes to help outfit the participants with gear such as harnesses, climbing shoes, snow shoes, overboots, skis, ski poles etc. Size can be approximate.

Does your child wear men's or women's shoe sizes?*

Shoe Size *

Weight *

Height *
Biking Ability: Our program is a beginner mountain biking course, however, it is strongly recommended that your child be comfortable on a bike before joining this course. Note that only Mount Jordan Middle School will be mountain biking. If the participant is from another school please choose "Not Applicable".*
What kinds of allergies does the participant have?
Animals
Food
Medications
Plants
Pollens
Stinging Insects
Other
None

Please describe the participant's allergies. Include the severity of the reaction and any medications used or carried.

Does the participant have any medical conditions we should be aware of such as asthma, high blood pressure, or a tendency to overheat?

What medications is the participant currently taking (including inhalers)?
Check any personal medical or mental health history for the participant.
ADHD/ADD
Anxiety
Autism Spectrum
Behavioral Addictions
Bipolar
Depression
Domestic Violence
Drug or alcohol use/addiction
Jail time/detention center
Learning disabilities
OCD
ODD
Panic Attacks
PTSD
Schizophrenia
Self Harm
Suicide attempt
Suicide Ideation (suicidal thoughts)

Comments for checked items

Does the participant have any physical/mental/emotional challenges that may require special accommodations? If so, please explain.
Has your child ever had any physical confrontations at home or school?*
No
Yes

If yes, please describe the situation and any calming skills your child uses.

Please describe any major events your child has struggled with and when it occurred (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.).

What are your goals for the course?

Personal medical insurance is required for the participant throughout the program.

Personal medical insurance is required for the participant throughout the program. *
I confirm that the participant is covered by active medical insurance and I will notify Pivot Adventure immediately if coverage is lost.
The participant is not currently covered by medical insurance.
I do not know

Primary Insurance Company *

Insurance Policy Holder's Name *

Relationship to Student *

Policy Holder's Phone 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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!