Voluntary and Medical Release Forms

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The Voluntary Release and the Medical Release forms need to be filled out by each individual participating in the Team Challenge Program.

VOLUNTARY RELEASE FORM

Participant's Name: _______________________________DOB____________ AGE _______

Address:____________________________________________________________________

Phone: ( )__________________________________

The Matagorda County TEAM Challenge Program you have signed up for involves physically and emotionally demanding activities in an outdoor setting. It includes climbing, jumping, and other rigorous activities on natural and man made structures that are on the ground or at low, medium, or high distances off the ground. You will be working with instructors from the Matagorda County Juvenile Department and with others in your group. It is possible that you may be injured while participating in the program either because of your own conduct, conduct of others in the group, conduct of the instructors from the Matagorda County Juvenile Probation Department, or the conditions of the premises. We want to make sure you understand the risks of injury before you decide to participate in the program. It is required that you read the following very carefully, make sure you understand it, and sign it before you begin participating in the TEAM Challenge Program.

BY SIGNING THIS RELEASE FORM, I AGREE TO RELEASE AND HOLD HARMLESS MATAGORDA COUNTY, IT'S OFFICIALS, OFFICERS, EMPLOYEES, CONSULTANTS, AGENTS, AND DIRECTORS, INCLUDING THE MATAGORDA COUNTY JUVENILE PROBATION DEPARTMENT AND THE MATAGORDA COUNTY JUVENILE BOARD, FOR ANY DAMAGE OR INJURIES, PHYSICAL OR MENTAL, WHICH MIGHT RESULT FROM MY PARTICIPATION IN THE TEAM CHALLENGE PROGRAM.

I RECOGNIZE THAT THERE IS A SIGNIFICANT RISK IN ANY ADVENTURE, SPORT, OR ACTIVITY ASSOCIATED WITH THE OUTDOORS. KNOWING THE INHERENT RISKS, DANGERS, AND RIGORS INVOLVED IN THE ACTIVITIES, I CERTIFY THAT I AM FULLY CAPABLE OF PARTICIPATING IN THE ACTIVITIES. I UNDERSTAND THAT I WILL NOT BE FORCED TO PARTICIPATE IN ANY ELEMENT THAT I FEEL UNCOMFORTABLE WITH. I FURTHER UNDERSTAND THAT MY IMAGE, BY PHOTOGRAPH OR VIDEO, MAY BE USED FOR PROMOTIONAL PURPOSES.

I ASSUME FULL RESPONSIBILITY FOR MYSELF FOR BODILY INJURY, DEATH, LOSS OF PERSONAL PROPERTY, AND EXPENSES THEREOF, AS A RESULT OF MY NEGLIGENCE, OR OTHER RISKS, INCLUDING BUT NOT LIMITED TO THOSE CAUSED BY THE OBSTACLE COURSE, THE TERRAIN, THE WEATHER, MY ATHLETIC AND PHYSICAL CONDITION, OTHER PARTICIPANTS OR INSTRUCTORS.

BY SIGNING THIS RELEASE FORM, I AGREE THAT IF I DO SUSTAIN PHYSICAL INJURY OR MENTAL DAMAGE OF ANY NATURE AS A RESULT OF MY DECISION TO PARTICIPATE IN THE TEAM CHALLENGE PROGRAM, I VOLUNTARILY AGREE TO HOLD HARMLESS THE ABOVE NAMED PARTIES FROM ANY LIABILITY THEREFORE AND THAT THIS RELEASE IS BINDING ON MY HEIRS, PERSONAL REPRESENTATIVES, AND ASSIGNS.

I ACKNOWLEDGE THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS REGARDING ANY ASPECT OF THIS RELEASE FORM AND BY SIGNING IN THE SPACE PROVIDED BELOW, I DO ACKNOWLEDGE THAT I HAVE READ COMPLETELY AND FULLY UNDERSTAND ALL ASPECTS OF THIS RELEASE FORM AND AGREE TO ITS TERMS IN ITS ENTIRETY.

PARTICIPANT'S SIGNATURE___________________________________DATE______________

PARENT/GUARDIAN (if participant is under 18) _________________DATE______________

APPLICANT INFORMATION AND MEDICAL HISTORY

Participant's Name: _______________________________DOB____________ AGE _______

Parent's Name (if under 18)_____________________________________________________

Parent's Social Security Number (incase of emergency)______________________________

Address:____________________________________________________________________

Phone: ( )___ Work: ( )_

Do you have any health problems or disabilities that may affect you ability to participate in the TEAM Challenge Program? If yes, please explain:

____________________________________________________________________________________

Please provide the following information (in case of emergency):

Person to notify:_________________________________ Relationship:__________________________

Phone: ( )_______________________

List any medicine that you are allergic to:

____________________________________________________________________________________

List any medication that you are currently taking:

____________________________________________________________________________________

List any other allergies (food, insect bites, poison ivy, etc...):

____________________________________________________________________________________

Health/Accident Insurance: Yes or No

Name of Company: _______________________________ Policy Number: ______________________

Do you have any of the following: (please circle one)

Problem with hearing Yes No

Chest Pains or exertion Yes No

Low or high blood pressure Yes No

Heart Attack Yes No

Hypoglycemia Yes No

Joint Pains, swelling, stiffness Yes No

Chronic pain in neck, back, arms, legs, or shoulders Yes No

Severe injuries to head, chest, internal organs Yes No

Dizzy spells, fainting, convulsions Yes No

Shortness of breath, asthma, or exertion Yes No

Palpation of heart, irregular heart beat, heart murmurs Yes No

Broken Bones, joint dislocations, weakness of muscles Yes No

Diabetes, Thyroid, or bleeding problems Yes No

If you answered yes to any of the above, PLEASE EXPLAIN:

____________________________________________________________________________________

The above information is complete and accurate to the best of my knowledge

PARTICIPANT'S SIGNATURE___________________________________DATE______________

PARENT/GUARDIAN (if participant is under 18) _________________DATE______________

DATE:____________________________

Matagorda County Juvenile Probation Dept.

Dennis Davis, Chief Juvenile Probation Officer

2004 Kilowatt Drive

Bay City, Texas 77414

(979) 244-5820 * fax: (979) 244-3849

E-Mail Questions or Comments to mcjp_dd@sbcglobal.net

Phone: ( )__________________________________

Phone: ( )_______________________ Work: ( )_____________________

Phone: ( )___ Work: ( )_