Teambuilding- Low Ropes

PLEASE PRINT:
Participant’s Name:________________________________________________________ Gender ________

Address:_____________________________________________________________________________________________
(Street) (City) (State) (Zip)

Phone: (home) (work)____________________________________ UID#:____________________________________

Check One: Student _________ Faculty/Staff ________ Public_______ E-Mail:______________________________

Minors (under the age of 18) must have their parent/guardian sign this form in order to participate.

WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

The undersigned wishes to participate in the Outdoor Adventure Program Low Ropes Course sponsored by the Campus
Recreation Department of Illinois State University (“ISU”). In consideration for the privilege of participating in this program, the
undersigned agrees to the following clauses.

1) The undersigned certifies that he/she is capable of participating in the Outdoor Adventure Program Low Ropes
Course. ISU reserves the right to deny anyone the opportunity to participate in the program.

2) The undersigned acknowledges and understands that participation in activities in the outdoors may involve above
normal risk and has hereby been made aware that participation in the Low Ropes Course has the following non-
exhaustive list of particular risks involved in the challenge course: falls, falling branches or equipment, sprains/strains,
inclement weather or death.

3) The undersigned hereby agrees to indemnify and hold harmless the Board of Trustees of Illinois State University, its
officers, employees, agents, and assigns from any and all claims, actions, suits, procedures, costs, expenses,
damages and liabilities, including attorney’s fees, brought as a result of my involvement in the Low Ropes Course.

4) I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and
understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the
agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability
to the greatest extent allowed by law.

5) I hereby agree to allow the Campus Recreation Department of the Board of Trustees of Illinois State University, and
persons acting for or through them the right to use, reproduce, assign, and/or distribute photographs, films,
videotapes, and sound recordings of myself, for use in materials they may create.

NAME OF CONTACT PERSON IN CASE OF EMERGENCY:

Name: ________________________________________ Complete Address:_________________________________________________

(street)

Phone: (Primary) (Secondary)

(city) (state) (zip)

Medical Insurance Carrier:________________________________________ Policy #__________________________________________

I do not have medical insurance or can not provide the information

but intend to participate and will pay my expenses if injured: ____________________________________________________________
(signed)

SIGNATURE _____________________________________________ DATE _____________________

(participant)

PRINTED NAME____________________________________________

Parent/Guardian signature of minor ______________________________________________________

**Please write any medical condition that may affect your challenge course experience such as pregnancy, recent surgeries or injuries on
the back of this form**