Skip to content
519 653 2337
Search for:
Search
Skip to content
About InnerSee
Solutions
Culture Transformation
Leadership Development
Team and Group Development
Organizational Transitions
Employee Experience
Priority Synchronization
Blog
Challenge Course
Contact
Sign Up form
Step
1
of
2
50%
Part 1
Challenge courses involve certain elements of risk. Accidents may occur while participating in these activities. These accidents may cause injury. They can result from the nature of the activity and can occur without any fault on either part of the participant, or Innersee Initiatives Inc. or its employees or agents, or the facility where the activity is taking place. By choosing to participate in the activity, you are assuming the risk of accident occurring. The chance of an accident occurring can be reduced by carefully following instructions at all times while engaged in the activity.
This form is to be read and signed by all participants on Innersee Initiatives Inc.’s Challenge Course.
PLEASE READ THIS CAREFULLY. IT AFFECTS CERTAIN RIGHTS YOU MAY HAVE IF YOU ARE INJURED OR OTHERWISE SUFFER DAMAGES PARTICIPATING IN THE ADVENTURE CHALLENGE COURSE.
In return for Innersee Initiatives Inc. allowing you to participate in the Challenge Course, and other good and valuable consideration, you agree, and state that on behalf of yourself, your heirs, assigns, executors and others, as follows. Check each of the boxes (parent/guardian if under age 18).
Name
*
First
Last
Organization
*
Date of Training
*
MM slash DD slash YYYY
Once familiar with any and all of the rules established for the Challenge Course activities, I will obey them, or exclude myself from an activity. I understand that a helmet is mandatory when participating on certain elements.
*
I agree
I understand and appreciate the inherent risks and dangers of participating in Challenge Course activities, initiative games, (including but not limited to the hazards of climbing or descending; walking on logs/wires suspended above the ground; travelling through field terrain; exposure to the forces of weather and/or nature; accidents or illnesses occurring in remote places without medical facilities; paddling or otherwise travelling through turbulent or calm waters; and travel by air, train automobile and/or other forms of transportation) which could result in PROPERTY DAMAGE AND PERSONAL INJURY, INCLUDING PERMANENT PARALYSIS AND DEATH; and I agree to accept all risks whether present or future, known or unknown, arising from or as a result of my participation in these activities. The risk of injury from the activities involved in this program could be significant and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of staff.
*
I agree
I HEREBY RELEASE AND HOLD HARMLESS INNERSEE INITIATIVES INC., their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, and all claims of damages, demands, and actions whatsoever resulting from my participation.
*
I Agree
I understand that most Challenge Course activities are led by trained and qualified part-time employees, NOT adventure professionals.
*
I Agree
I understand I must be healthy and reasonably fit in order to safely participate in the Challenge Course and that I will inform the staff of any medication, ailment, condition, or injury that may effect performance.
*
I Agree
I understand that Innersee Initiatives Inc. is in no way responsible for the loss, damage or theft of any items I bring with me to their site.
*
I Agree
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK MANAGEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAV GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
*
I Agree
Part 2 - Health Information
Health Insurance
*
OHIP
UHIP
Private Insurance
None
Health Insurance #
If applicable, please enter the number related to your choice above.
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
*
Birth Date
*
MM slash DD slash YYYY
Please complete the following as thoroughly as possible. Program leaders and any emergency medical personnel will be the only users of this information. All material is confidential and will be shredded after participation. (You may request it back)
1. What physical disabilities or conditions (heart conditions, diabetes, seizures etc) do you have that might affect your participation in this activity including operations, illness, or broken bones in the past six months?
*
2. Any allergies, specifically bee stings, food, or medication/drugs?
*
3. List any medications being taken
*
4. Name, location, and phone number (if known) of family physician
*
5. Please identify any special dietary needs:
*
6. Emergency contact name:
*
Emergency contact relationship
*
Emergency contact phone
*
I understand that I am responsible for my personal medical insurance. In the event that I am rendered unable to communicate due to illness, accident, or emergency while participating in the Challenge Course, I hereby give permission to the physician selected by the Challenge Course personnel, to hospitalize, secure proper treatment for, and to take whatever medical actions necessary to treat me.
*
I Agree
Comments are closed.
