MEDICAL SCREENING QUESTIONNAIRE
The ROPES course program by intention places students in physically, mentally, and emotionally challenging situations.
Participation in ROPES activities by persons with certain pre-existing medical conditions can exacerbate those conditions and/or increase one’s risk of harm while on the ROPES course.
It is, therefore, imperative that you respond openly and honestly to the following questionnaire in order that we along with you and your physician, can access whether or not your participation in these activities is appropriate.
1. Please note any pre-existing injury or illness or other condition that might be aggravated by your participation in these activities.
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2. List any medications that you are currently taking.______
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3 Do you have a history of heart disease or high blood pressure? Y N
4. Do you have any allergies to foods, insects, or medications? Y N
5. Do you have any physical weaknesses that might lead to injury, i.e.: Back Problems. Y N
6. Do you foresee any physical problem resulting from your participation in these activities? Explain:______
7. Are you suicidal? Y N
8. Do you feel coercion to participate in the ROPES course? Y N
I have seriously considered the questions and my answers on this form. I have gathered information about the nature of the risk encountered on the ROPES course and have answered the questionnaire honestly and fully. I have talked with my physician (if appropriate) about my concerns and we have decided that I will take on the challenge and informed risk associated with the ROPES program.
Name______Date______
RELEASE OF LIABILITY-READ BEFORE SIGNING
I, ______, the undersigned, in consideration of being allowed to participate in any way in the RCSD ROPES Program, it’s related construction, training, events and or activities, acknowledge, appreciate, agree, and accept that my participation is completely of my own choosing.
Further, I fully understand that:
1. The risk of injury from the activities involved in this program is significant, including; the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the facilitators immediately; and,
4. I, for myself, and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS RCSD officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers and, if applicable, owners and lessors of premises used for the activity (''Released"), WITH RESPECT TO ANY AND ALL, INJURY, DISABILITY, DEATH, or loss or damage to person or property to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
______AGE______DATE______
PARTICIPANT'S SIGNATURE
FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE UNDER AGE 18
This is to certify that I as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
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PARENT/GUARDIAN'S SIGNATURE EMERGENCY PHONE #(S) DATE SIGNED