Fillable Misawa Outdoor Adventure Program Assumption of Risk, Hold (35th Force Support Squadron)

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Misawa Outdoor Adventure Program Assumption of Risk, Hold (35th Force Support Squadron)

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Misawa Outdoor Adventure Program Assumption of
Risk, Hold Harmless, and Indemnity Form
I, _____________________________ hereby WAIVE, RELEASE AND HOLD HARMLESS
The United States Air Force, its agents and employees, and any other person connected formally
or informally with the Misawa Outdoor Recreation Program as chaperon, trip leader, or
otherwise their respective heirs, personal representatives, successors and assigns from any and all
claims for injuries or damages or otherwise which may arise from any reason whatsoever as a
result of my participation in the said Outdoor Recreation Program FOREVER.
I acknowledge that I AM RESPONSIBLE for the condition of my own personal well-being,
health, and equipment. Personal effects are MY sole responsibility. I further acknowledge that
____________ is a dangerous sport or activity and various injuries may occur including, but not
limited to, cuts, scrapes, bruises, traumatic injuries, and death. I further understand that events
out of the control of the Outdoor Recreation Program may unwillingly create these situations and
therefore HOLD HARMLESS and INDEMNIFY any and all of the aforementioned entities
FOREVER.
In the event of storm, inclement weather, acts of God, vehicle malfunction, equipment
malfunction, breakdown, strikes, work stoppages, or other causes or events beyond the control of
the United States Air Force, its agents and employees, I shall pay and be responsible for all costs,
charges, and expenses arising out of but not limited to charges imposed by carriers, lodging
management, destination area, equipment rental stores, or otherwise.
I know that growth of vegetation, debris of various types, and many other hazards or obstacles,
marked or unmarked, exist within the area(s) of this particular activity/trip: I assume the dangers
involved and WAIVE any right to hold liable the United States Air Force, its agents and
employees of any liability whatsoever for the conditions or events that may unfold due to those
conditions, at the area(s) involved FOREVER.
I am further made aware that it is my responsibility to inform the Outdoor Adventure Guide(s) of
any and all conditions, physical or otherwise, that might limit my abilities during trips and
programs that may include, but are not limited to, physically demanding exercise or movement,
water activity, heights, fine motor skills, and mentally and emotionally stressful situations.
Failure to do so, could limit the ability for productive patient care in the event of an
accident/incident. I am also fully aware that advanced medical care could be hours away based
on trip locations.
Moreover, I have provided emergency contact information on the reverse of this form.
Emergency contacts must include individuals that are not a participant in the same trip.
I have read the above and agree to the conditions stated.
__________________________________ _______________________________
(Signature) (Date)
________________________________ _______________________________
(Signature of Parent or Guardian if Minor) (Date)
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Misawa Outdoor Adventure Program Assumption of
Risk, Hold Harmless, and Indemnity Form
Terms:
INDEMNIFY – The act of agreeing to secure another against an anticipated loss or damage.
WAIVE - To abandon or forsake a right.
RELEASE - The giving or discharging of a right of action which a person has or may claim against
another.
HOLD HARMLESS - In a contract, a promise by one party not to hold the other party responsible if the
other party carries out the contract in a way that causes damage to the first party.
Participant Contact Information
Name: _______________________________________________________________________
Primary Phone Number: _________________________________________________________
Email Address: ________________________________________________________________
Emergency Contact Information
Name: _______________________________________________________________________
Relationship: __________________________________________________________________
Primary Phone Number: _________________________________________________________
Secondary Phone Number: _______________________________________________________
Medical Information
The information provided is confidential and will not be shared with individuals who are not Misawa
Outdoor Recreation Staff or Medical Professionals. It will be kept in accordance with the Privacy Act
Statement, Misawa Outdoor Adventure Program, provided for your review. Medical information will help
us to better prepare for our adventure and prevent any unnecessary problems.
1. Do you have any history of allergies or anaphylactic reactions? (please circle) YES NO
If yes, please explain._____________________________________________________
2. Do you have any history of asthma? (please circle) YES NO
If yes, do you carry an inhaler with you? (please circle) YES NO
3. Do you have any history of diabetes or hypoglycemia? (please circle) YES NO
If yes, do you carry insulin with you? (please circle) YES NO
4. Do you have any history of heart disease or high blood pressure? (please circle) YES NO
Pertinent Medical History:
Please list any other medical conditions, dietary restrictions, injuries, or other limiting factors which our
staff should be aware of, and may affect your ability to safely perform the proposed activity:
“I hereby certify that I do not have any know medical conditions that may interfere with my
ability to safely perform the activity or activities of _______________________________”
__________________________________ _______________________________
(Signature) (Date)
__________________________________ _______________________________
(Signature of Parent or Guardian if Minor) (Date)
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Misawa Outdoor Adventure Program Assumption of Risk, Hold (35th Force Support Squadron)

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Completed 25 July 2021

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