PARTICIPANT MEDICAL FORM

To be filled out by parent/legal guardian.

Completed form is required.


If parents/guardian cannot be contacted, please contact (list two individuals)

Medical Health Insurance

List any food allergy (nuts, fish, peanut butter, dairy, etc.). If no food allergies please write N/A.

List any other allergies. Include: drug allergies (penicillin, sulpha, iodine, etc.), insects (bee stings, etc.), hay fever (pollen, mold, etc.), others.

Pre-Existing Medical Conditions
Does the participant have any of the following? Please check all that apply:

I give permission to Eco-Experience Program to give the following if deemed necessary to relieve minor pain and discomfort.

I request that the above named participant be permitted to carry the following medication.
Please note: if there’s any risk of anaphylaxis, the participant MUST bring an epipen and carry it at all times. If none please write N/A.

The above noted “self-carry” items/medications are permitted for the indicated participant at all times. He/she has been instructed by the physician and parents and acknowledges the proper understanding of the purpose, frequency, and appropriate method of use of these items.

In case of an emergency, every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the physician selected to hospitalize and secure proper treatment (including emergency care) for my child.

ACKNOWLEDGE OF FULL UNDERSTANDING
I understand and acknowledge that the program(s) in which I (or my child) will participate has risks and may be physically strenuous. It is impossible to anticipate every activity in which I (or my child) will engage. Eco-Experience offers numerous courses with a wide variety of activities. The list below includes many of those activities. The activities in my (or my child’s) course will depend on the program in which I am (or my child is) enrolled but may include: hiking, backpacking, camping, including cooking over stoves, open fires or by other means; ropes and/or challenge courses (traversing ropes suspended off the ground, potentially at great heights, rock, wall or tower climbing; physical problem-solving activities; water activities including flat water or white water boating, rafting, canoeing, or kayaking, swimming; river crossings; vehicle travel and travel by public, chartered or other conveyance; community and other service projects that may involve using tools, power equipment, ladders, or construction materials.

I understand that I (or my child) may engage in other activities not listed above. The program plan may be modified for any number of reasons, including convenience, weather, emergencies, or unexpected conditions. Activities may take place in the United States or in foreign countries and may be supervised or unsupervised. In particular, participants may have time alone in remote areas. Participants may also be in urban or other areas with exposure to individuals who are not under Eco-Experience’s supervision or control. It is impossible to know or list every risk associated with every activity. Risks will depend on the program. Some, but not all, of the risks I (or my child) may encounter include: unpredictable or harsh weather; earthquakes; lightning; exposure to extreme temperatures (high heat or extreme cold); exposure to high altitude, avalanches and rock fall; rapidly moving water including whitewater and rough seas; drowning; wild animals and marine life; disease carrying or poisonous plants, insects, animals, and marine life; improper or malfunctioning equipment; slipping, falling or being struck by objects or persons; risks caused or complicated by any mental, physical, or emotional conditions any participant may have; being separated from other participants and leaders for considerable periods; physical contact with other participants or other individuals; and other natural or man-made hazards. Another risk is the potential misjudgment by Eco-Experience instructors, volunteers, other staff members, co-participants or contractors related to my (or my child’s) participation, including but not limited to decisions regarding my (or my child’s) physical condition and capabilities, weather, water, terrain, route or medical treatment. All of these risks are inherent to the activities in my Eco-Experience program, which means that they cannot be changed or eliminated without altering the essential elements of the activity.

I acknowledge that participating in an Eco-Experience program involves inherent risks and other risks, hazards, and dangers including some not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma, or disability. Furthermore, activities may take place several hours or days from any medical facility or where communication, transportation, or evacuation is subject to delay. I understand that Eco-Experience cannot ensure my (or my child’s) safety and does not seek to eliminate all of these risks, in part, because they facilitate the educational and other objectives of the program. I agree to assume all of the risks of the activities of my (or my child’s) Eco-Experience program, whether inherent or not and whether described above or not.

LIABILITY RELEASE AND INDEMNITY AGREEMENT
I hereby forever release, waive, and discharge Eco-Experience Program, and each of its respective agents, employees, officers, directors, trustees, independent contractors, volunteers, and all other persons or entities acting under their direction and control (collectively referred to as “the Released Parties”) from, and agree not to pursue a claim or sue the Released Parties or any of them for, any liability, claim, or expense in any way associated with my (or my child’s) enrollment or participation in the Eco-Experience Program or the use of any equipment or facilities.

Neither I nor anyone acting on my (or my child’s) behalf will make a claim against the Released Parties as a result of any injury, illness, damage, death, or loss. This release includes any losses caused or alleged to be caused, in whole or in part, by the negligence, whether active or passive, of the Released Parties to the fullest extent allowed by law (but not for gross negligence) and includes claims for injury, property damage, wrongful death, breach of contract, or any other type of suit. I further agree to defend and indemnify the Released Parties (to pay or reimburse the Released Parties for money they are required to pay, including attorney’s live to learn 7 fees and costs) with respect to any and

all claims brought by or on behalf of me, my child, a family member, personal representative, estate, a co-participant, or any other person for any claims related to my (or my child’s) enrollment or participation in the program or my (or my child’s) use of equipment or facilities, including claims that Eco-Experience Program instructors, staff, or volunteers were negligent.

This indemnity includes payment for attorney’s fees and costs incurred by the Released Parties in defending a claim or suit if the claim or suit is withdrawn or where a court determines that the Released Parties are not liable for the injury or loss. The National Park Service and certain Forest Services may not allow for the assumption of risks other than the inherent risks or for the release of liability for claims of negligence. Therefore, for activities that occur on lands controlled by these agencies where and to the extent that such a prohibition is in writing for that particular location, program, or permit at the time of the incident and found by a court of proper jurisdiction to be enforceable as a matter of law, the assumption of risk in the above paragraph is limited to assuming the inherent risks; the release of liability is inapplicable; and the indemnity agreement is limited to claims brought by or on behalf of a co-participant or person other than the student or a family member of the student. The assumption of all risks, the entire indemnity provision, and the release of liability shall remain in full force and effect for all activities or any portion of activities which do not transpire on lands controlled by these federal provisions. The indemnity provision for payment of attorney’s fees when a suit is withdrawn or where a court determines that the Released Parties are not liable applies to all activities regardless of where they take place.

The assumption of risk, release, indemnity agreement, and all other provisions in this document are intended to be interpreted and enforced to the fullest extent allowed by law. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions, which shall continue in full force and effect.

I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT. I UNDERSTAND THAT I AM SURRENDERING CERTAIN LEGAL RIGHTS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, MY MINOR CHILDREN AND OTHER FAMILY MEMBERS, AND MY HEIRS, EXECUTORS, REPRESENTATIVES, AND ESTATE. I HEREBY WARRANT THAT I HAVE LEGAL AUTHORITY TO ACT ON MY CHILD’S BEHALF. I AGREE, ON MY OWN, AND ON MY CHILD’S BEHALF, TO THE TERMS AND CONDITIONS IN THIS DOCUMENT.

If participant is under the age of 18 (or if participant is a resident of Alabama and is under the age of 19) (or if participant is a resident of Mississippi and is under the age of 21) at the time this document is signed, a parent or legal guardian must sign.