Experience Learning · AHSP 2023 Activity Waiver

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AHSP Medical Release Waiver for Activities

Please make sure every member of your party fills out a Medical Release Waiver. Parents/Guardians may sign in place of minors. Minors cannot participate in an activity without an adult present.

Contact Information

Participant Name

First Name

Last Name

Date of Birth

(mm/dd/yyyy)

Emergency Contact Name

Emergency Contact Phone Number

Medical Information

Current and Recent Medical Conditions

Please list all medical conditions that you have been diagnosed or treated for within the past year. Include any injuries, illnesses, psychiatric treatment, counseling, eating disorders, attention deficit disorders, etc. If diabetic, please include contact information for diabetic nurse/physician.

Allergies

Please list all allergies to foods, medications, insects, etc.,

Insurance

I certify that I have health insurance

Yes

Medical and Liability Release

I understand that Experience Learning programs may involve canoeing, hiking, camping, and other outdoor activities. I understand the inherent risks involved in these activities and that unanticipated dangers may arise. I voluntarily assume all risk of loss, damage, illness or injury, including death, which may occur while I am participating in any activity or event associated with Experience Learning or during such times I am under the supervision of any employee or agent of Experience Learning. I agree to hold harmless and release Experience Learning and its volunteers, employees, and agents in any location where activities are conducted. If a medical emergency does occur and I am unable to respond or cannot readily be consulted, Experience Learning may select any licensed physician to secure and administer medical treatment, including hospitalization and surgery if and as needed. I understand any medical expense so incurred will be my financial responsibility. I have listed all the information concerning allergies, medical history or conditions, dietary restrictions and regular medication I take.

COVID-19 Release

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Experience Learning has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Experience Learning can not guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Experience Learning staff.
I voluntarily seek services provided by Experience Learning and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19.

More regularly updated information on our COVID-19 policies can be found here.

Permission to use Images

Experience Learning relies on the use of images of program activities and participant feedback for recruitment purposes, as well as to report to and solicit financial donors. Experience Learning staff members often take photographs informally throughout a program and these serve as our image library. Also, participants are asked to complete evaluations at the end of a course. By signing below you agree that Experience Learning has the right to use pictures or statements by, of, or about you for aforementioned uses.

Initial Here to agree to permission to use images

Signature

Sign here to indicate that you have read the Medical and Liability Release and all other releases and agree to the terms listed above. By signing here, you are consenting to the use of your electronic signature in lieu of an original signature on paper.