Liability Waiver and Indemnification

I acknowledge that my participation in the Challenge Adventure Program (including the ropes course) at Sertoma 4-H Center may involve risks including but not limited to falls, friction burns, and other potential personal injuries and property damage. I assume responsibility for all risks. I indemnify and hold harmless North Carolina State University, its trustees, officers, employees, agents, including the staff and volunteers of the Sertoma 4-H Educational Center, from any liability arising from, or proximately caused by my participation in this program.

I further acknowledge that I have comprehensive health insurance coverage that will be in effect during the date(s) of this camp/program. The insurance company is: ___________________________________________ and my policy number is _________________________.

Printed name ________________________________________ Age ______________________

Signature ___________________________________________ Date ______________________

IF PARTICIPANT IS LESS THAN 18 YEARS OF AGE:

I am fully aware of the risks that may be involved, and I consent to have my child participate in the aforementioned camp/program. Insurance coverage is indicated above.

___________________________________________________________
Parent/Guardian Printed name

___________________________________________ ______________________
Signature Date

Emergency Contact Information:

Name of Participant: ___________________________________________________

Age: _________ Weight: ___________

Any known allergies or medical conditions:

Person to notify in the event of an emergency:

Name: _____________________________ Phone Number (s) : ____________________________

Relation to participant: ______________________________

Permission to Treat:

I hereby give permission to authorized camp personnel to provide my child with first-aid treatment while at camp. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, injections, and/or surgery, for the person named above. This completed form may be photocopied for trips out of camp.

Signature of parent/guardian or adult participant: __________________________________Date: ___________