On Belay · Overnight Program Waiver

Wilderness/Overnight Program Health Survey

In order for us to provide a safe, inclusive, and healthy environment for On Belay participants, we require a more detailed medical history than is provided in the Participant Health Form & Waiver.

Please include detailed answers to the following questions. It is imperative that we have a full understanding of your child's health, allergies, and medications to lead a safe and successful trip.

Contact Information

Participant's Full Legal Name *

First Name

Last Name

Parent/Guardian Full Legal Name *

Prefix

First Name

Last Name

Suffix

Email *

Verify Email *

Child's Health Information

Please provide details of all allergies the participant may have including food (I.e. gluten, nuts, etc.), pharmaceutical drugs, and environmental varieties. If the participant has no allergies, please mark N/A. *

For the allergies listed above, please describe what happens when the child is exposed to the allergen (i.e. hives, upset stomach, anaphylaxis). *

Please provide details around all medications your child will need to take during the duration of the trip. If the participant does not take any medication, please mark N/A. *

Please format: Name of medication, dosage, time of day, mode [oral, topical, spray, chewable, liquid]

In order to provide reasonable accommodations and plan a fun trip for all our participants: Please detail any relevant medical and behavioral conditions that the participant currently experiences and has a history of. *

Please include current and historical mental, physical, and emotional health details.

Dietary Restrictions * *

Vegetarian

Vegan

Kosher

Halal

Gluten Intolerant

Celiac

None

Other

Lunch Day One is PBJ and Ham/Turkey/Cheese

Day 2 Lunch Request *

Option 1: Wheat Bread, Turkey, Cheddar, Lettuce, Tomato

Option 2: Spinach Wrap, Hummus, Cucumber, Lettuce, Tomato

Option 3: Wheat Bread, Ham, Cheddar, Lettuce

Option 4: White Bread, Sun Butter, Jelly

Day 3 Lunch Request *

Option 1: Wheat Bread, Turkey, Cheddar, Lettuce, Tomato

Option 2: Spinach Wrap, Hummus, Cucumber, Lettuce, Tomato

Option 3: Wheat Bread, Ham, Cheddar, Lettuce

Option 4: White Bread, Sun Butter, Jelly

Day 4 Lunch Request *

Option 1: Wheat Bread, Turkey, Cheddar, Lettuce, Tomato

Option 2: Spinach Wrap, Hummus, Cucumber, Lettuce, Tomato

Option 3: Wheat Bread, Ham, Cheddar, Lettuce

Option 4: White Bread, Sun Butter, Jelly

Does your child have an EpiPen or use an inhaler. *

Yes

No

Please describe your child's experience in similar overnight programs. If your child has not participated in an overnight trip, please note that here. *

You can be as detailed or brief as you would like.

Does your child know how to swim? *

We may have opportunities to swim throughout the trip.

Yes

No

Rate your child's comfort around water. *

On a scale of 1 (totally uncomfortable) to 5 (very comfortable) rate your child's comfort level around water.

Rate your child's comfort with heights. *

On a scale of 1 (totally uncomfortable) to 5 (very comfortable) rate your child's comfort level with heights.

Gear

Please refer to the detailed packing list in the trip overview/orientation email. Every item on the list will be required for participation on the trip, but most of the items can be borrowed free of charge through On Belay's partnership with the AMC's Highland Center Gear Room. The following items can be borrowed from the AMC. Please check all the boxes to indicate which items you would like to borrow. Please note that participants will be responsible for all borrowed clothing and gear. If anything is lost or damaged during the trip, On Belay will bill participant families for the replacement cost, determined by the AMC.

Shoe Size (Please specify Men's, Women's, or Youth) *

Pant Size (Please specify Men's, Women's, or Youth) *

Shirt Size (Please specify Men's, Women's, or Youth) *

Backpack Size (Please specify Men's, Women's, or Youth) *

Refer to the size guide below to determine approximate backpack size.

Backpack Sizing

Wilderness/Travel Waiver of Liability & Hold Harmless Agreement

1. In consideration for receiving permission for my child to participate in an On Belay Inc. Overnight Program during the current calendar year:

I hereby release, waive, discharge, and covenant not to sue On Belay Inc. (“On Belay”), its officers, servants, agents, volunteers, contractors, and employees (hereinafter referred to as the “Releasees”) from any and all liability, claims, demands, actions, and causes of action whatsoever, arising out of or relating to any loss, damage or injury, including death, that may be sustained by me and/or my Child, or to any property belonging to me or my Child, whether caused by the negligence of the Releasees, or otherwise, while participating in the Programs, or while in, on or upon the premises where the Programs are being conducted, while in transit to or from the premises, or in any place or places connected with the Programs.

2. I understand that the Programs may include a camping experience in a wilderness or semi-wilderness environment. I also understand that the Programs will include participant transportation to and from the Programs’ location(s) in a rental vehicle operated by the Releasees. I hereby release, waive, discharge, and covenant not to sue Releasees any injury to the above named participant during the program or during transport in rental vehicles unless caused by their willful misconduct.

3. I am fully aware of risks and hazards connected with traveling to and participating in the Programs, and I am fully aware that there may be risks and hazards unknown to me connected with traveling to and participating in the Programs, and I hereby elect to voluntarily participate and or have my Child participate in the Programs, to travel to and engage in activities knowing that conditions may be hazardous, or may become hazardous or dangerous to me and/or my Child and the property of either of us. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me or my Child, or any loss or damage to property owned by me or my Child, as a result of either of our travel to and participation in the Programs, whether caused by the negligence of Releasees or otherwise except for willful misconduct.

4. I further hereby agree to indemnify and save and hold harmless the Releasees and each of them, from any loss, liability, damage or costs they may incur due to my or my Child’s travel to and participation in the Programs, whether caused by the negligence of any or all of the Releasees or otherwise except for willful misconduct.

5. It is my express intent that this Release shall bind the members of my family and spouse if I am alive, and my heirs, assigns, and personal representative and those of my Child, if I or my Child are deceased, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named Releasees.

In signing this release, I acknowledge and represent that: I have read the foregoing release, understand it, and sign it voluntarily as my own free act and deed; No oral representation, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen years of age and fully competent, and have the legal capacity to act on behalf of my Child. I execute this Release for full, adequate, and complete consideration fully intending to be bound by the same.

*

I Agree

Parent/Guardian Signature *

Type your name in the box to agree all information is correct and you agree to submit this form.

Date *

(mm/dd/yyyy)