Team Synergy, Inc.

AGREEMENT TO PARTICIPATE; Ropes Courses/RENT the ROCK

ASSUMPTION OF RISK AND RELEASE OF LIABILITY

 

PLEASE READ THE FOLLOWING BEFORE SIGNING:

 

WHEREAS, THE UNDERSIGNED (“the APPLICANT”) wishes to be accepted for participation in a Ropes Course/Challenge Course Training Workshop or other Adventure-based program to be organized and conducted by Team Synergy, Inc., of Huntsville, Texas: and in consideration of Team Synergy, Inc.’s action in allowing the applicant to participate in such a program. The applicant also allows use of their photo and/or comments for print materials:

 

The undersigned acknowledge(s) that during the said Training Workshop that the Applicant has requested to participate in, that certain risks and dangers exist.  These include, but are not limited to the hazards of traveling mountainous terrain, depending on other people and being at various heights (ground to over 80’), accident or illness in remote places without medical facilities, the forces of nature and travel by air, train, boat, automobile or other conveyance.  The undersigned further recognizes that these risks may also include loss or damage to personal property, physical or psychological damage and / or injury not excluding fatality due to accidents which may occur, including accidents resulting from this course experience or other type of outdoor activities.  I further understand that participation in the activities I am requesting to participate in, I will be exposed to the effects of natural elements, including temperature extremes, and inclement weather. 

 

I certify that I am completely healthy (both physically and emotionally) and capable of participating in this Training Workshop.  I have listed on the Health Statement Form any medical condition that Team Synergy, Inc. should be aware of, which may hinder my participation in the Workshop.  However, I understand that it is solely my responsibility to determine whether there is any medical reason that I should not participate in the workshop, and I do not rely on Team Synergy, Inc. for any assessment of my health or ability to participate in these activities.

 

In consideration of, and as part payment for the right to participate in such a program and the services arranged for me by Team Synergy, Inc., its Shareholders, Directors, Officers, Employees, Agents, and /or Associates (hereafter referred to collectively as “Team Synergy”), I have and do hereby assume all the above risks and any other ordinary risk incidental to the nature of the trip/training which are not specifically foreseeable, and, for myself, my representative, assigns, heirs, and next of kin, will release and HOLD HARMELESS Team Synergy from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss or otherwise, whether caused by negligence of Team Synergy or otherwise, which I now have or which may arise from or in connection with my program or participation in any other activities arranged for me by Team Synergy, Inc. its Shareholders, Directors, Officers, Employees, Agents, and /or Associates, and their heirs, executors and administrators, successors and assigns and for all members of my family, including any minors accompanying me.  In short, I cannot sue Team Synergy, Inc. and if I do I cannot collect any money.  In addition, I will be liable for Attorney and Court fees associated with any litigation against Team Synergy, Inc.  I also state that I am not under, and will not be under the influence of any chemical substance including alcohol.  I fully understand that my physical activity involves risk of injury.  I also understand that my participation in this Team Synergy, Inc. activity is completely and entirely VOLUNTARY.  I enter this workshop and take full responsibility for my decision to participate or not to participate and agree to follow all safety instructions.

 

I hereby give permission to the medical personnel selected by Team Synergy, Inc. to order injections and/or anesthesia and/or surgery for me.  Such authorization for emergency treatment shall also include, but not be limited to; charges incurred for the providing of aid and arranging evacuation if Team Synergy, Inc. or its agents, determined that such evacuation is necessary or desirable.  I further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned.  I also understand and agree to abide by any restrictions placed on my activities.

 

___________________________________________

NAME OF PARTICIPANT (Please Print)

 

___________________________________________                                 Date of Signature _________________

SIGNATURE OF PARTICIPANT (18 YEARS AND OLDER)

 

______________________________________________________    Date of Signature  _______________________

SIGNATURE OF WITNESS                or GUARDIAN IF PARTICIPANT IS YOUNGER THAN 18.

 

 

 

Team Synergy, Inc. HEALTH STATEMENT FORM

The proposed activity provided by Team Synergy, Inc. requires participation in physical exercises, which are, by their nature, physically demanding.  Many of the activities will challenge you, and cause surges in blood pressure and pulse rates.  It is imperative that you are free of any heart related or other diseases.  Therefore, all participants must be free of medical or physical conditions, which might create undue risks to themselves or any others that depend on them.  Good physical condition will increase your enjoyment of outdoor activities.  If there is any doubt about your ability to safely participate in this experience, you should consult a physician for a complete examination.

                                                                                                                                S.S. #                ________________

Name ____________________________________________                    Birth Date _______________          

Address ___________________________________________                       Gender                ________________

City, ST, Zip _______________________________________                  Age                 ________________

Work Ph. (        ) ________________  Home Ph. (        ) ____________________________________

Name of Physician __________________________                  Date of last physical exam _________

In case of emergency notify _______________________________    Relation _________________

Home Address __________________________________________         Home Ph. ________________

City, ST, Zip ___________________________________________       Work Ph. ________________

 

Health History:  (Circle the appropriate answer and describe any YES answers.)

1.  Have you had or do you currently have any heart problems (dates):                                    

___________________________________________________________
YES     
NO

2.  Do you frequently suffer from pains in your chest:                                                                    

___________________________________________________________
YES        
NO   

3.  Do you often feel faint or have spells of severe dizziness:                                                                   

___________________________________________________________
YES       
NO

4.  Has a doctor ever told you that you have high blood pressure:                                               

___________________________________________________________
YES 
NO
5.  Are you a smoker:                  (If YES, how many pack per day?) __________
YES 
NO       

(NOTE:  IF YOU HAVE EVER HAD ANY HEART RELATED PROBLEMS YOU WILL NEED TO HAVE A RELEASE FROM A PHYSICIAN IN ORDER TO GO THROUGH A HIGH ELEMENT TRAINING.)

6.  Do you have arthritis joint or back problems that might be aggravated by exercise:               

___________________________________________________________

 YES   NO

7.  Have you had any operations, organ transplants, or serious injuries (dates):                                  

___________________________________________________________

 YES NO

8.  Do you have any disabilities or chronic recurring illness:                                                              

___________________________________________________________

 YES NO

9.  Are there any activities to be limited/discouraged by physician’s advice:                               

___________________________________________________________

 YES  NO

10.  Are you allergic to any medicines, insects or pollen: (Do you have an Eppy Pen?)                             

___________________________________________________________

 YES   NO
11.  Do you have Epilepsy:  ____________________________________ YES  NO
12.  Do you have Diabetes:  ____________________________________   YES NO
13.  Do you have any prescribed meal plan or dietary restrictions: ______  YES NO

14.  Are you currently sick and/or using a medication that is not listed above:                                 

___________________________________________________________

 YES NO
15.  Do you carry family medical/hospital insurance:  ________________  YES NO

                                  

                                                                    

16.     Carrier:  ________________  Policy #:  ______________________________________________

17.     Suggestions or health related information for Team Synergy, Inc. personnel:  ________________

18.     General Health Statement: I am in EXCELLENT, GOOD, FAIR, POOR health.  (Circle one.)

Explain:  __________________________________________________________________________

REPRESENTATION AND EMERGENCY AUTHORIZATION

This health history is correct so far as I know, and believe that my health is satisfactory to participate in challenge course activities. I hereby give permission to the medical personnel selected by Team Synergy, Inc. to order injections and/or anesthesia and/or surgery for me.  Such authorization for emergency treatment shall also include, but not be limited to; charges incurred for the providing of aid and arranging evacuation if Team Synergy, Inc. or its agents, determined that such evacuation is necessary or desirable.  I further agree to assume responsibility for the costs of any specialized means of evacuation and of any medical care and acknowledge that these costs are the financial responsibility of the undersigned.  I also understand and agree to abide by any restrictions placed on my activities.  I release all personnel from any claim whatsoever on account of first aid, treatment or service, whether deemed negligent or otherwise, rendered me during participation in ropes courses/rock climbing.

 

Signature of Participant:  __________________________________________________  Date:  ____________

 

Witness:  _______________________________________________________________