Facilitated Activities at Camp Allendale

Facilitated Activities at Camp Allendale

Camp Allendale provides facilitated activities that can include Archery, warm-ups and group initiative/team building problems, low ropes course elements, rock climbing at our Climbing Tower, swinging on our Giant Swing, and zipping on our Leap of Faith zip line. The level of participation in a facilitated Camp Allendale activity is at all times completely up to the individual’s choice. There is a risk, which must be assumed by each participant, that he or she may suffer an emotional or physical injury. Bruises and scratches are not uncommon.

Wearing weather-appropriate clothing as well as proper shoes is vital to each participant. Those who do not have closed heel and toe shoes will not be allowed to participate in activities.

Camp Allendale’s policy for participation in any facilitated activity requires that every participant have health/accident insurance coverage or assume the cost of any medical intervention. In addition, certain health/medical information must be made available to Allendale. This information will be held in confidence.

Release of Liability

I understand that Camp Allendale facilitated activities are physically and emotionally demanding and create risks and danger. I affirm that my health is good, and that I am not under a physician's care for any undisclosed condition that bears upon my fitness to participate in the facilitated activities.

I acknowledge and assume the responsibility to follow the directions of the staff or facilitators during these activities. I understand all activities are presented as "Your Challenge, Your Choice" and that my participation in any such activities is purely voluntary, and I elect to participate in spite of the risks. I am also able to limit my participation in activities as I see fit. If at any time during an activity I want to stop, it is my responsibility to inform my facilitator.

Before participating in any activity, I agree to assess my medical, physical and emotional condition, and based upon such assessment I will decide whether any such condition could interfere with my safety in any such activity, in which case I will decline to participate. I understand that Camp Allendale's facilitators are not qualified to determine who should or should not participate in any activity. I declare I am not now under the influence of any alcohol and/or drugs and I will not be under the influence of any alcohol and/or drugs during my participation of activities at Camp Allendale. I recognize that if my group is going to be participating in the Leap of Faith zipline, I am under the weight limit of 260 pounds.

By participating I agree to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any condition I may have and by my participation in the activity. I hereby waive, release, and discharge Camp Allendale, its staff, facilitators, and Board of Directors, from any and all liability, action, claim and damages, of every kind and nature. This waiver and release shall be construed broadly to the maximum extent under applicable law in the state of Indiana. My signature on this document shall bind my next of kin, heirs, representatives, administrators, successors and assigns on my behalf.

Type Signature

Draw Signature

Click to Sign

October 4, 2023

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

Continue

Group Information

Attending Camp Allendale with which Group? *

Date(s) Your Group will be at Camp Allendale *

Second Participant's Name

First Name*

Middle Name

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Third Participant's Name

First Name*

Middle Name

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Fourth Participant's Name

First Name*

Middle Name

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Fifth Participant's Name

First Name*

Middle Name

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Sixth Participant's Name

First Name*

Middle Name

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Seventh Participant's Name

First Name*

Middle Name

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Eighth Participant's Name

First Name*

Middle Name

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Ninth Participant's Name

First Name*

Middle Name

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Tenth Participant's Name

First Name*

Middle Name

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

Do you have health/accident insurance?*

Yes

If yes, please list the name of the company and policy number:

Do you have any limiting physical disabilities or handicaps (temporary or permanent)?*

Yes

If yes, identify and explain

Are you currently taking any medication (prescribed or otherwise)?*

Yes

If yes, state what you are taking and what condition it is for:

Do you have any allergies, reactions to medications, or any other medical limitations?*

Yes

If yes, identify and explain

Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant

Parent or Guardian's Email Address

Email*

Confirm Email*

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.

Agree To This Document