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Wilkes University - Adventure Education Waiver Medical

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ADVENTURE EDUCATION
PROGRAM WAIVER & RELEASE OF LIABILITY
Adventure Education is experiential learning and strives to cultivate, encourage and develop self-awareness, hard and soft skills,
environmental stewardship and an overall a sense of wellness. The program's objective is to introduce participants to fun, engaging
experiences both indoors and outdoors so they may learn through trying, doing and practicing in a supportive culture. We teach
responsibility, preparedness and trained-knowledge in respect to our adventures.
Participants in the Adventure Education program may take part in activities including, but not limited to:
Hiking
Yoga
Rock climbing / Rock wall
Low ropes/high ropes
Backpacking
Glamping
Pre-orientation adventure day
activities
Mountain & Urban biking
Ice skating
Ballroom dancing
Rafting & Kayaking
Skiing and Snowboarding
Participates should be aware that they may be exposed to dangers, risks, and/or hazards associated with participating which include
the use of, act of, and/or exposure to, but not limited to the following:
1. Unpredictable weather conditions including lightning, storms, wind, rain, snow, ice, cold, heat, weather changes, and
changes in water level, and potential problems associated with back country navigation;
2. Travel in a vehicle driven by a person other than self;
3. Use of specialized equipment and problems due to defects in manufacturer’s products or arising from the improper use of
products;
4. Carrying/lifting over 50lbs;
5. Physical exertion associated with the movements involved with outdoor adventure activities that can cause fatigue,
soreness, sprains, abrasions, fractures, joint stiffness, and blisters;
6. Wounds and injuries to skin, organs, muscles, joints, and bones;
7. Uneven terrain, extreme temperatures or conditions;
8. Contact with traffic, pedestrians, and/or other participants;
9. Accidents, illness, or other problems in remote places without cell phones, other means of communication, or easy access
to medical facilities;
10. Injuries inflicted by animals, plants, UV rays, or other natural forces;
11. Exposure to natural and man-made fire; and
12. Hazards related to water including wading, swimming, or capsizing into water containing cold temperatures, rocks, trees,
currents, rapids, re-circulating holes, waterfalls, man-made objects, or other obstacles in the water. This can result in
hypothermia, injury, entrapment, or drowning
Each Participant is responsible for determining if he or she is physically able to participate in the activities offered by the program. It
is always advisable to consult a physician prior to participating in any Adventure Education activities.
I hereby acknowledge and understand that there are dangers and risks associated with the activities described above, which may
not be fully explained to me. I hereby agree to abide by all rules, instructions, policies and procedures imposed by Wilkes University
relating to the use of the facilities, property and equipment.
By signing this Waiver and Assumption of Risk, I fully assume the dangers and risks, and agree to use my best judgment while
engaging in those activities. I further agree to indemnify and hold harmless Wilkes University, its trustees, officers, employees, and
agents from and against any and all liability incurred as a result of or in any manner related to my participation in the Adventure
Education activities.
I hereby affirm that I have read and fully understand the above and agree to be legally bound by it. I ALSO AFFIRM I AM OVER 18
YEARS OF AGE. If under 18 years of age, a parent/guardian signature is required.
________________________________ __________________________________ ________________________
Participant Name (Please print) Participant’s Signature Today’s Date
________________________________ __________________________________ ________________________
Parent or Guardian Name (Please print) Parent or Guardian Signature Today’s Date
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Page 1 of 2
ADVENTURE EDUCATION
MEDICAL QUESTIONNAIRE & DISCLOSURE AGREEMENT
This medical questionnaire provides us with information required for course management and emergency situations. By requesting
this medical history, we do not imply that we have the expertise to assess your physical condition, or your ability to participate safely
in this program. If you have any doubts about your ability to participate in this program, please consult with your physician. Please
complete fully so that instructors can adjust program activities as needed to meet your needs and manage your participation and
the participation of others. This information is confidential and will be shared only as needed with trip leaders, instructors and
medical care providers.
In consideration of my participation in Wilkes University Adventure Education Programs (hereafter referred to as “activity”), I offer
the following information on my current medical condition:
PARTICIPANT INFORMATION
Name: ________________________________________________ Age: _______ DOB: ___________________ Male Female
Home Address: _______________________________________________________________________________________________
City: _________________________ State: ______ Zip Code: ____________ Primary Phone Number: __________________________
Wilkes ID Number (if available): _________________________________ E-mail Address: ___________________________________
Health Insurance Policy Provider: __________________________________________ Phone: ________________________________
Policy, Contract, and/or Group Number: ___________________________________________________________________________
EMERGENCY CONTACT
In the event of an emergency please notify: ________________________________________________________________________
Relationship to participant: _____________________________________________________________________________________
Emergency Phone Numbers (please list two): _________________________________ /_____________________________________
Do you have a history of or currently have any of the following? Check appropriate boxes below:
No Yes Heart attack, heart disease, heart
palpitations/murmur
No Yes Hypertension
No Yes Chest pain/pressure, angina
No Yes Stroke
No Yes Smoking
No Yes Diabetes
No Yes Epilepsy, seizures, or neurologic concerns
No Yes Mental health concerns
No Yes Gastrointestinal concerns
No Yes Genitourinary concerns
No Yes Asthma or other respiratory concerns
No Yes Musculoskeletal injury
No Yes Infectious disease or blood-borne pathogen
No Yes Dietary restrictions
No Yes Allergies (insects, foods, drugs)
No Yes Frostbite, cold injury, or Raynaud’s
Syndrome
No Yes Heat illness
No Yes Altitude illness
No Yes Pregnancy
No Yes Recent injury/illness
No Yes Corrective lenses
No Yes Sleepwalking
Page 2 of 2
Allergies: Do you have any allergies (e.g., bees, drugs, foods, etc.)? Describe the nature of your allergic reactions.
Dietary Needs (only for trips where food is provided):
Chronic Illnesses: List any (e.g. diabetes, asthma, etc.) and suggest any helpful activity modifications.
Physical Condition/Ability: List any physical or ability considerations and suggestion any helpful activity modifications.
Medications: Are you taking any medications? If so, what are they? What are they for?
Injuries: List any injuries (e.g., dislocations, sprains, etc.), indicate severity, and identify when they occurred. Have you fully
recovered from this injury?
Physician: Are you currently being treated by a physician (or have been in the past year)? Have you been hospitalized within the
past year? If so, please explain.
Concerns: Do you have any special needs or concerns about your access to or participation in this program that you would like
the Outdoor Adventures staff to be aware of?
To the best of my knowledge, the preceding information is an accurate representation of my pertinent medical history. I
declare that I am in good physical health and believe that I am able without reservation or limitation to cope physically
with the rigors of this activity. In the event of an emergency, I grant permission for any evacuation, transportation,
medical intervention, and/or care that may be necessary for my immediate wellbeing. I further authorize the release of
any relevant medical information to any medical facility or personnel as necessary to my immediate well-being.
_______________________________ _________________________________ ___________________________
Participant Name (Please print) Participant’s Signature Today’s Date
________________________________ _________________________________ ___________________________
Parent or Guardian Name (Please print) Parent or Guardian Signature Today’s Date
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Wilkes University - Adventure Education Waiver Medical

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Completed 24 February 2020

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