MEDICAL FORM AND LIABILITY RELEASE

www.theuswshow.com Ph (+61) 434 091 653

Group: Ultimate Spirit Warriors/Jesus Ministries/Angel TV/Maris and Pax Cordova/Shannett Fischer/Lisa Kincaid

Event Dates:date to date

Participant Information:

Name: First NameMiddle NameLast Name
Address: Number and StreetCity:City
State/Province: State or ProvinceZip Code:Zip/Postal Code
Phone: Phone Email Address: Email Address
Height:Enter Height Weight:Enter Weight Date of Birth: Date of Birth Age: Gender: Male☐ Female☐

Emergency Contact:

Parent or Guardian Name: Emergency Contact Name Phone:Phone
(this person MUST Sign the back of this form if participant is under 18)
Alternative Contact:Alternate Contact Name Phone:Phone
Primary Care Physician:Click here to enter text. Medical Office Click here to enter text. Phone:Phone
Insurance CarrierClick here to enter text. Policy Number:Click here to enter text.

Allergies:

Bee Sting: Yes☐/No☐ Treatment for past stings: Benadryl☐ Epi-pen☐ Drug Allergies:

Food Allergies(List)List Food Allergies Here Other Allergies(List):List Other Allergies Here
Medications:
(Important! All medications MUST be brought in the original container with doctors instructions)
Activity Restrictions: Physical Handicaps:
LimitingFears? Date of last known Tetanus Shot:
Dietary Restrictions? Date of Last physical exam:

Health History: We request that you volunteer any conditions below so that may best serve you and comply with state regulations. Please complete all items and list the year for any that apply.

☐ADD/ADHD

☐Anemia

☐Appendicitis

☐Asthma

☐Back Pain or Injury

☐Bedwetting

☐Bleeding/Clotting

☐Blood Pressure (high/low)

☐Bronchitis

☐Colitis

☐Concussion/Head Injury

☐Corrective Lenses

☐Cramps, serve

☐Cystitis

☐Dental Appliances

☐Diabetes

☐Diarrhea/Constipation

☐Dislocations

☐Eating Disorder

☐Emotional Behavior

☐Epilepsy or Convulsions

☐Fainting or Dizziness

☐Fractures

☐Frequent Ear Infections

☐Gall Bladder Disorder

☐Migraine Headaches

☐Motion Sickness

☐Pneumonia

☐Skin Conditions or rashes

☐Sleepwalking

☐Sprains or Strains

☐Tuberculosis

☐Tumor or Growth

☐Ulcer

☐Urinary Difficulties

☐Hay Fever

☐Heat Stroke or Exhaustion

☐Heart Disease or Defect

☐Hepatitis A,B,C

☐Hernias

☐Joint or Muscle Pain

☐Knee Injury or Trouble

Details on all current conditions noted above:Type details here.
List any other recent injuries, illnesses or disabilities with date of occurrence:List here.
Recent Hospitalizations or Surgeries:Type here to enter text.

_____By initialling, I grant the Ultimate Spirit Warriors / Jesus Ministries / Angel TV or the First Aid Provider permission to administer over the counter “Medications” such as Ibuprofen, Paracetamol, Antacids etc. as needed and as determined by the First Aid Practitioner on Duty.

MEDICAL FORM AND LIABILITY RELEASE

www.theuswshow.com Ph (+61) 434 091 653

Group: Ultimate Spirit Warriors/Jesus Ministries/Angel TV/Maris and Pax Cordova/Shannett Fischer/Lisa Kincaid Event Dates:date to date

Participant Name:Full Name

Medical Authorization and Insurance Coverage

This health information is correct, as far as I know. In the event the emergency contact cannot be reached in an emergency during the program dates noted in this form, I hereby give permission to the physician selected by the Ultimate Spirit Warriors / Jesus Ministries / Angel TV / Maris and Pax Cordova/ Shannett Fischer/Lisa Kincaid to hospitalize, to secure proper treatment, to order injections, anaesthesia, dental care, and or surgery for the applications. I GIVE PERMISSION for the Ultimate Spirit Warriors / Jesus Ministries / Angel TV / Maris and Pax Cordova/ Shannett Fischer/Lisa Kincaid to provide for the applications a certified first aid provider to administer first aid and over the counter medications as needed for illness or injury as well as any medications noted. I AGREE that photocopies or faxes f this complete form are to be considered legally valid and binding for trips off the camp property. I AGREE to obtain and maintain personal insurance covering the applicant in the program. In the absence of the aforementioned insurance, I AGREE to pay all cost of rescue and/or medical services as may be incurred by the applicant in the absence of personal insurance.

Acknowledgement of Risk and Capabilities

I recognize that there is a significant element of risk in any sport or activity associated with the outdoors and this program. These risks may include but are not limited to falling trees, rocks or other objects, poisonous plants, reptiles and insects, domesticated and wild animals, crossing steep, uneven and loose terrain, exposure to the elements, lightning strikes, fires, stream crossing, open untreated water, flash floods, landslides, freezing water temperatures, the withholding of breakfast and lunch, depending on other group members for physical and emotional safety, contact with abrasive or slippery rocks, equipment failure or misuse, injury from entanglement with ropes, cables and other equipment, lack of sleep, mock acting of aggression and at times a remote location far from modern medical facilities and rescue assistance. I AM AWARE that certain portions of the program are physically demanding and that the applicant may be asked to walk, run, stretch, climb, push, pull, and perform rigorous and potentially risky or dangerous physical activates which may double their normal resting heart rate. I VOLUNTARILY AGREE to participate in the program. I realise that pre-existing medical conditions could affect the applicant’s ability to participate in the program, I FURTHER AGREE to get a qualified medical opinion if the applicant is over 50 years old and or if I doubt their ability to participate in any given activity. I AGREE to abide by the activity restriction and to participate only to the extent that my medical, physical, emotional, or other conditions create no undue risk to myself, other participants, or the program staff. I FURTHER ACKNOWLEDGE that exposure to these inherit risks, rigors and dangers may result in but is not limited to separation from the group, bruising, scrapes and scratch, sprains, body injury, emotional trauma, permanent disability including loss of sight and in extreme cases death. Knowing these risk and potential consequences, I CERTIFY that the applicant is fully capable of participating in the program activities which may include but not limited to hiking, backpacking bouldering, rock climbing, rappelling, initiative games, low ropes, high ropes, caving, mountain biking, paintball horseback riding, fishing, swimming, water sports, canoeing, sailing, powered water crafts, white water rafting, archery, batting case use, individual sports including skateboarding, team sports, except as noted under activity restrictions.

Assumption of Responsibility

I AGREE to assume full responsibility for the applicants actions and their consequences during their participation in the program and including without limitation, any injury to the applicant and or property or an inconvenience resulting there from any other circumstance related to such actions, I, the applicant, AGREE to follow the programs rules communicated to me verbally by the program staff.

Covenant of Good Faith

I AGREE the Ultimate Spirit Warriors/Jesus Ministries/Angel TV/Maris and Pax Cordova/Shannett Fischer/Lisa Kincaid has the right to refuse an applicants it judges to be incapable of meeting the rigor and requirements of participating in these activates. I AGREE that any decision made by the staff of the Ultimate Spirit Warriors / Jesus Ministries / Angel TV / Maris and Pax Cordova will be binding upon the applicant. The Ultimate Spirit Warriors/Jesus Ministries/Angel TV/Maris and Pax Cordova/Shannett Fischer/Lisa Kincaid reserves the right to dismiss any applicant (at their own expense) who through their actions or in-actions, influences or causes an event which is detrimental to the best interest of themselves or others.

Permission for participations, Transportation and Promotion

I GRANT PERMISSION for the applicant to engage in all the Ultimate Spirit Warrior activities and to be transported by program staff members and volunteers who is legally licensed to drive on all activities sponsored by the Ultimate Spirit Warriors / Jesus Ministries / Angel TV / Maris and Pax Cordova on and off the location property for the durations of the program. I GIVE PERMISSION for the Ultimate Spirit Warriors/Jesus Ministries/Angel TV/Maris and Pax Cordova/Shannett Fischer/Lisa Kincaid to use images, voice recording, video recording of the applicant taken while at the program and quotations from evaluations, interviews relating to the program experience for promotional and commercial purposes.

Waiver of Liability

I HEREBY RELEASE and agree to INDEMNIFY, DEFEND AND HOLD HARMLESS Ultimate Spirit Warriors, Jesus Ministries, Angel TV, Maris Cordova, Pax Cordova, Shannett Fischer, Lisa Kincaid, its board of directors, officers, directors, employees, guides, agents, volunteers and each and every land owner, municipality and or governmental agency upon whose property the activity is conducted, from an and all liability, claims, losses, costs, expenses (including without limitations, attorney fees) or demands (except those arising from the gross negligence or wilful misconduct of the aforementioned parties) that I, my heirs, executors, trustees, administrators, assignees, distributes, personal or legal representation and all members of my family, may now have or in the future make against such parties as a result of or related to any injury, loss, death or damage of any kind whatsoever resulting from the applicants participation in this program or from any driving mishap that may occur during transportations.

Acceptance Signature

I/WE HAVE READ AND UNDERSTOOD AND ACCEPTED the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon the applicants thereafter.

Participant Signature or Legal Guardian (if under 18): X date

Please Check One: Parent☐ Guardian☐ Self ☐