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ASSUMPTION OF RISK/LIABILITY RELEASE

I am aware in signing this document for participation in Eagle Rock’s program that certain elements of the activity are physically and emotionally demanding. Furthermore, I understand that certain risks and dangers, such as those listed below, exist in the activities in which I am participating. These risks include: loss of damage to personal property, injury, or fatality. The above risks may be caused by, but not limited to: travel to and from activity site, inclement weather, slipping, falling, insect bites, falling objects, immersion in cold water, hypothermia, suffering any type of accident/illness in remote areas without easy access to medical facilities. I acknowledge that while Eagle Rock and its staff will make every reasonable effort to teach me proper outdoor techniques to minimize exposure to known risks, all hazards and dangers associated with this activity cannot be foreseen. I have a personal responsibility to learn and follow the safety rules and procedures established by the Eagle Rock staff and will make them aware at any point in which I question my knowledge of these procedures or my ability to participate in any activity.

In consideration of being allowed to participate in the Eagle Rock program, which includes its Christian based Bible and prayer ministry, I hereby personally assume for myself, or for my minor child, as the case may be, all risks in connection with said program for any injuries or dangers which may occur to myself or my child as participants and do fully and forever release Eagle Rock, its owners, employees and agents from any and all claims, demands, dangers, rights of action or causes of actions, present of future, whether the same be known, anticipated or unanticipated, resulting from or arising out of the participant’s commencement of the activity or use of the facilities, equipment and property of Eagle Rock except in the case of Eagle Rock’s sole negligence. I understand that the activity chosen may not be the safest, but has been chosen for its interest and challenge. I do, for myself and on behalf of my minor child as the case may be, agree to indemnify and hold harmless Eagle Rock and its affiliates and the employees and agents thereof from any liability and expense for personal or property damage, or injury not caused by their negligent actions.

My signature on this document is also intended to bind my successors, heirs, representatives, administrators and assigns. 

I hereby authorize the Eagle Rock staff to consent to emergency examinations and/or diagnostic procedures, procurement of medical treatment, emergency surgery, or administration of necessary anesthetics, when in the opinion of any physician or surgeon of good standing such medical treatment is deemed necessary for the mental or physical health or the participant and I/we cannot be reached within a reasonable time to obtain my/our consent to treatment. This grant of authority shall not create an independent duty on the part of Eagle Rock employees to consent to treatment. If the participant is under 18 years of age, this form must be signed by parent or legal guardian

Today's date: November 26, 2024

First Participant's Name

First Name*

Middle Name

Last Name*

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Third Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Fourth Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Fifth Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Sixth Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Seventh Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Eighth Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Ninth Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
Tenth Participant's Name

First Name*

Middle Name

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
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

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy 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*

Middle Name

Last Name*

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

Age

Height

Weight

Eye Color
Health History (please check or list if applicable)
Dizziness, fainting spells
Back problems
Knee Problems
Severe abdominal/menstrual cramps
Frostbite, hypothermia
Emotional impairment/disability
Recent sprains, fractures, dislocations
Present use of alcohol/drugs/medicines
Thyroid trouble
Do you require an epipen, inhaler etc?
Severe allergies (food, stings, drugs, etc.)
Current medications
Heart problems
History of heart trouble
Low or High blood pressure
Epilepsy or convulsions
Diabetes
Current communicable diseases
Dietary restrictions
Currently pregnant

Please explain any items checked or any condition, injury, or other illness requiring medical treatment which might restrict or prevent full participation in the program for which you are applying. *

Please be advised that any of our food products may have come in contact or contain allergens, including peanuts.


Date of Last Tetanus Booster

Other immunizations and dates
Swimming Ability (please check) *
Non-swimmer
Swimmer
I give Eagle Rock my permission to use pictures of me (or my child, if a minor) in future Eagle Rock marketing or outreach presentations.*
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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