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Steppin' Out 

Waiver of Liability, Indemnity Agreement,

&

Assumption of Risk and Health Questionnaire

Waiver: In consideration of permission to participate, today and on all future dates, the property, facilities and services of Willamette University (WU), I, on behalf of myself, my heirs, personal representatives, or assigns, do hereby release, waive, discharge, and covenant not to sue WU, its directors, officers, employees, student volunteers, independent contractors, administration, or trustees from liability from any and all claims arising from the ordinary negligence of WU or any of the aforementioned parties. This agreement applies to personal injury including paralysis or death, from accidents or illness arising from participating in WU activities including, but not limited to, organized activities, classes, observation, and individual use of facilities, premises, or equipment; and to any and all claims resulting from the damage to, loss of, or theft of property.

Indemnification and Hold Harmless: I also agree to HOLD HARMLESS AND IMDEMNIFY WU from all claims resulting from ordinary negligence and to reimburse them for any expenses incurred as a result of my involvement with the WU. I further agree to pay all costs and attorneys’ fees incurred by WU in investigating and defending a claim or suit if my claim is withdrawn, or to the extent a court or arbitration determines that WU is not responsible for the injury or loss.

Severability & Venue: The undersigned further expressly agrees that the foregoing waiver and assumption of risk agreement is intended to be as broad and inclusive as is permitted by the law of the State of Oregon and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Likewise, I agree that if legal action is brought, it must be brought in Marion County, Oregon.

Acknowledgment of Understanding: I have read this waiver of liability and indemnification agreement and fully understand its terms. I understand that I am giving up substantial rights, including my right to compensation for injury. I acknowledge that I am signing the agreement voluntarily, and intend my signature to be a complete and unconditional release of all liability for ordinary negligence to the greatest extent allowed by law in the State of Oregon.

Signature of Participant if 18 and over. If 17 and under a parent/guardian must sign 


Date June 1, 2025

 

Assumption of Risks: Physical or outdoor activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. WU accesses many outdoor venues for activities such as hiking, backpacking, nordic & alpine skiing, spelunking, rafting, paddling, hiking at altitude, mountain climbing and rock climbing. Some of these activities involve strenuous exertions of strength using various muscle groups, some involve quick movements involving speed and change of direction, and others involve sustained physical activity, which places stress on the cardiovascular system.

The specific risks vary from one activity to another, but in each activity the risks range from minor injuries such as scratches, scrapes, insect bites and stings, bruises and sprains to major injuries such as loss of sight, joint or back injuries, skeletal breaks, tissue tears, burns, concussions, and heart attacks to catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know the nature of the activities within this WU activity I am registered for, and I understand the demands of those activities relative to my physical condition and skill level, and I appreciate the types of injuries, which may occur as a result of activities made possible by WU. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Acknowledgment of Understanding:I have read this assumption of risk and fully understand its terms. I acknowledge that I am signing the agreement freely and voluntarily and intend my signature to signify a complete assumption of the inherent risks of participating in or observing outdoor recreational activities from WU to the greatest extent allowed by law in the State of Oregon.


Signature of Participant if 18 and over. If 17 and under a parent/guardian must sign


Date June 1, 2025

Parent or Guardian's Email Address
Email
Email me a copy of this document.
First Participant's Name
First Name*
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
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*
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Health Information

HEALTH QUESTIONNAIRE

To be used exclusively by program staff to ensure the safety of all participants by gathering the most appropriate accommodations to be prepared for the needs of participants.

What is the preferred way to contact you with questions about anything noted on this form? *
Text
Phone
Email
Other
Identify an alernative if you chose 'Other' above
Please provide the best number and best times to reach you. If you chose phone, do you prefer to talk or text? *
1. Does the participant have any allergies (insects, food, medicine, plant-based, etc.)?*
No
Yes

If you answered YES, please list the allergy(ies) below along with severity of reaction and medication needed: (write N/A if not applicable) *

2. What phobias or significant fears does the participant have that might impact their experience (claustrophobia, fear of heights, etc.)? (Write N/A if not applicable) *

3. Please list any food restrictions (e.g. vegetarian, vegan, kosher, gluten-free, including foods you do not like, etc.). (Write N/A if not applicable) *
4. Please check the box next to each medical conditions listed below which the participant currently has or has had in the past: *
chronic illness
recent surgeries
asthma
high blood pressure
ligament/tendon problems
back/shoulder/knee/ankle injuries or bone fractures
not applicable
breaks or fractures

For each condition identified above, please describe the participant's experience with the condition. (Write N/A if not applicable) *

5. Please list any health conditions that may require us to adapt our physical activity of the program. Include a list of any medications (along with frequency of use) you will be taking while enrolled in the program to help us manage any physical and emotional health concerns during the experience. (Write N/A if not applicable): *
6. What is the year of the participant's last tetanus immunization: *
7. How comfortable is the participant around water? (There is potential to wade into creeks and lakes or to use watercraft with staff supervision.)*
Very comfortable: I am a strong swimmer and/or trust my capacity to manage entering and exiting water safely in most common conditions.
Comfortable: I am able to enter and exit water safely without great anxiety.
Cautious: I can enter water in conditions where I feel safe, but not all water opportunities are desirable to me.
Discomfort: I do not like nor desire to enter bodies of water.

8. Please tell us 2 to 3 interests or hobbies the participant has that they could talk about for longer than five minutes.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you consent to use your electronic signature in place of an original signature on paper. You have the right to request a paper copy to sign instead. By checking here, you are waiving that right. After consent, you may request a paper copy of the 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 you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. Always ensure we have a current email address to contact you regarding any necessary changes.


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