CANTER'S CAVE 4-H CAMP
ADVENTURE PROGRAM PERMISSION FORM
NAME: ___________________________________ AGE: ________ PHONE: ____________________
ADDRESS: _____________________________________________________________________________

Emergency Medical Information
(If "Yes", please explain on the lines following the question.)
NO ___ YES ___ Allergies to foods, drugs, insect bites, dust, etc. Please identify them and the nature of your reaction. _______________________________________________________
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NO ___ YES ___ Physical disabilities or conditions which might limit your participation: ____________
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NO ___ YES ___ If you are presently taking medication (s), please identify them: __________________
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In Case of Emergency Contact:
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Name Relationship Home Phone Work Phone

Statement of Understanding
I am aware in signing this statement for participation in programs of 4-H Camp Ohio that certain activities are physically demanding. Therefore, physical fitness will increase the enjoyment and ability to participate in the activity. If for any reason I question the ability of the participant to participate in the activity, I will consult with the instructors prior to participation. While it is impossible to foresee all possible dangers, some of the specific hazards which might be encountered while participating in adventure programs include: slipping or falling on the trail, bumps, bruises, cuts, insect bites, poison ivy, sprains, fractures or other injures. I understand that most activities are conducted in the out-of-doors in all kinds of weather, so proper dress (rain gear, warm clothing) are essential to avoid undue exposure to known risks; however, as a participant, I acknowledge the nature of the activity and the fact that not all of the stresses and hazards connected with the activity can be foreseen. I have the personal responsibility to follow the established safety rules and procedures to the extent that I participate in such activities. If at any time I have questions about the activity, I have the responsibility to consult with my instructor. Sponsoring agencies have the responsibility of providing a progression of appropriate activities which lead to the experiences at 4-H Camp Ohio.

I recognize that there is a significant element of risk in any adventure, sport or activity associated with the outdoors. Knowing the inherent risks, dangers and rigors involved in the activities, I certify that the participant (including any minor children) is fully capable of participating in the activities.

I assume full responsibility for the participant (including minor children), for bodily injury, death, loss of personal property and expenses thereof, as a result of my negligence or the negligence of the participant.
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Signature

Date
(Parent or legal guardian must sign for all persons under 18 years of age.)
Note: All participants should wear long pants (no shorts) and tennis shoes on the high ropes course.