ADK Youth Program Release Forms | Adirondack Mountain Club

ADK Program Release & Medical Information – Youth 12 and Under

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Before you arrive, thoroughly read all program materials, and call us if you have any questions at 518-523-3441 ext. 1. The Acknowledgment of Risk statement, Release of Liability, Photo Release sections of this form must be completed and signed before you can attend the program.

Safety is a fundamental part of the ADK (Adirondack Mountain Club) operation. Safety is taught and practiced on every program offered by the ADK. Despite operating to the best of our capabilities, the possibility of an accident still exists. We cannot – nor can anyone – reduce that possibility to zero.

The following consent is applicable to programs and guided trips that you are taking with ADK this year.

ACKNOWLEDGMENT OF RISK

In consideration of the services of the Adirondack Mountain Club, their employees, members, trip leaders, chapters, groups, representatives or agents and all other persons or entities acting in any capacity on their behalf (collectively referred to as ADK), I agree as follows:

I acknowledge that this program entails known and unanticipated risks, which cannot be eliminated without destroying the unique character of this activity. The same elements that contribute to the unique character of this activity can be causes of loss or damage to my equipment, accidental injury, illness, or in extreme cases, permanent trauma, disability, or death.

I understand that ADK does not want to frighten me or reduce my enthusiasm for this activity, but thinks it is important for me to know in advance what to expect and to be informed of the activities’ inherent risks. The following describes some, but not all, of those risks:

ADK programs camp and travel out of doors, where they are subject to numerous risks, environmental and otherwise. Activities vary from program to program, and include hiking and backpacking, rock climbing, mountaineering, whitewater and flat water canoeing and kayaking, skiing, snowshoeing, fishing, and trail work. In the backcountry, meals are prepared over gas stoves and water requires disinfection before use. Camping risks and hazards includes burns, cuts, diarrhea and flu-like illness. ADK programs occur in remote places, many hours from medical facilities. Communication and transportation can be difficult and sometimes evacuations and medical care may be delayed. Travel is by vehicle, canoe, kayak, skis, on foot and by other means, over rugged unpredictable terrain, including stream crossings, snow and ice, steep slopes, slippery rocks, and downed timber. Environmental risks and hazards include rapidly moving, deep, or cold water, insects, falling or rolling rock, lightening, avalanches, floods, and unpredictable forces of nature, including weather which may change to extreme conditions without notice. Possible injuries and illnesses include hypothermia, frostbite, sunburn, heatstroke, dehydration, and other mild or serious conditions. Decisions are made by the instructor(s) and participants in a wilderness setting, based on a variety of perceptions and evaluations which by their nature are imprecise and subject to errors in judgment. Throughout the course, participants are responsible for their own safety and for the safety of other members of their course.

I am aware that ADK programs include risks of injury or death to myself. I understand the description above of these risks is not complete and that other unknown or unanticipated risks may result in property loss, injury, or death. I expressly agree and promise to accept and assume all the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary, no one is forcing me to participate, and I elect to participate in spite of and with full knowledge of the inherent risks. I agree to be solely responsible for my own safety and to take every precaution to provide for my own safety and well-being.

I have read, understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon myself, my heirs, assigns, personal representatives and estate and all members of my family. With full knowledge of these dangers, I hereby agree for myself, all of my family members and heirs to RELEASE ADK and any of its employees, members, trip leaders, chapters, officers, directors, governors, or agents liability claims demands or any causes of action and agree NOT TO MAKE ANY CLAIM against ADK or any of its chapters, representatives or agents whatsoever which may arise during my participation in the program stated above.

RELEASE OF LIABILITY

I intend this RELEASE OF LIABILITY to be effective whether or not any loss, damage, injury or death results, in whole or in part, from the negligence of the ADK, or any of its agents, employees, officers, instructors, guides, directors, governors, trip leaders and/or members. I understand that negligence means a failure to do an act which a reasonable and careful person would do, or the doing of an act which a reasonable and careful person would not do, under the same circumstances, to protect himself, herself or others from injury or death.

I assume full responsibility for my personal injuries, including injuries resulting in death, which might occur as the result of my own negligence and/or the negligence of lack of care of ADK, its employees, members, chapters, trip leaders, groups, representatives or agents. I agree to be solely responsible for my own safety and to take every precaution to provide for my own safety and well-being while participating in this program.

PHOTO RELEASE

I hereby give to and grant to the Adirondack Mountain Club, Inc., the unrestricted right and permission to use and publish any and all photographs and/or videos which its employees, assignees, licensee, or representatives may have taken of me for any purpose whatsoever, including (but not limited to) illustration, program promotion, publicity, and advertising.

I hereby release the Adirondack Mountain Club, Inc. from any and all claims and causes of action arising out of use of said photographs and/or videos of me, including any and all claims for libel.

Photo Release Consent

I hereby consent to the terms of the PHOTO RELEASE

I am over the age of eighteen. I have read the foregoing PHOTO RELEASE and state that I fully understand the meaning of them.
I have read, understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be
effective and binding upon me, my heirs, assigns, personal representatives and estate and all members of my family.

Acknowledgement of Risk & Release of Liability Consent*

I hereby consent to the terms of the ACKNOWLEDGMENT OF RISK & RELEASE OF LIABILITY

I am over the age of eighteen. I have read the foregoing ACKNOWLEDGMENT OF RISK and RELEASE OF LIABILITY and state that I fully understand the meaning of them. I have read, understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representatives and estate and all members of my family.

Signature*

Participant Name*

First Last

Today's Date*

Month

Day

Year

IF UNDER 18 YEARS OF AGE, PARENT OR GUARDIAN MUST READ AND SIGN BELOW: **MUST SIGN BEFORE PARTICPATING IN PROGRAM.**

Parent/Guardian Photo Consent

I hereby consent to the terms of the PHOTO RELEASE on behalf of the named minor

I am the legal guardian of the above minor and have read the above and I hereby consent to the terms of the PHOTO RELEASE on behalf of the
named minor.

Parent/Guardian Acknowledgement of Risk & Release of Liability Consent

I hereby consent to the terms of the ACKNOWLEDGMENT OF RISK, RELEASE OF LIABILITY, and PHOTO RELEASE on behalf of the named minor

I am the legal guardian of the above minor and have read the above and I hereby consent to the terms of the ACKNOWLEDGMENT OF RISK and RELEASE OF LIABILITY on behalf of the named minor, and give my consent to the participation of the above named minor in all activities of ADK on the terms stated.

Signature

Parent/Guardian Name

First Last

Today's Date

Month

Day

Year

The following information will be applicable to any programs and guided trips that you are taking with ADK this calendar year.

GENERAL INFORMATION

Participant Name*

First Last

Participant Pronouns

Phone (Parent or guardian information if participant is under 18 years old)*

Email (Parent or guardian information if participant is under 18 years old)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

EMERGENCY CONTACT

Name*

First Last

Relationship*

Email*

Daytime Phone*

Evening Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

INSURANCE COVERAGE

Participant is responsible for their own medical expenses. ADK requires that anyone participating in a program have their own medical coverage in the event that an injury occurs to the participant either before or after the program begins. The information requested below is for the primary family policy holder.

Insurance Company*

Insurance Company Phone #*

Certificate/Policy ID #*

Group # (if applicable)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Policy Holder*

First Last

Phone*

Place of Employment

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physician/Primary Care Provider’s Name

First Last

Phone

MEDICAL & PHYSICAL INFORMATION

Date of Birth*

MM slash DD slash YYYY

Age

Height (ft, in)

Weight (lbs)

Gender

Swimming Ability

Cannot Swim

Can Swim 100 feet

Can swim 500 feet

Strong Swimmer

Exercise*

Activity

Frequency Per Week

Approx. Time/Distance

Intensity Level

Please describe your current activity.

Do you have any allergies?*

Yes

Allergies

Please list all allergies including medicines, food, bites, stings, shellfish, iodine, plants, and animals. Leave blank if none.

Allergy

Reaction

Medication Required

Do you take any medications?*

Yes

Medications

Please list all prescription and non-prescription medication you take and/or carry with you. Leave blank if none.

Medication

Condition

Dosage (amount/frequency)

Initiated (month/year)

Side Effects

Do you have any dietary restrictions?*

Yes

Dietary Restrictions

HEALTH HISTORY

Please check the appropriate boxes, and respond to all questions below.

Have you had operations/serious injuries in the past five years?*

Yes

Have you made any hospital/emergency room visits in the past year?*

Yes

Do you have diabetes? If yes, please list if you are insulin dependent below.*

Yes

Do you have epilepsy or a seizure disorder?*

Yes

Do you have other past or current medical issues/illness/requirements?*

Yes

Have you had a heart attack/by-pass surgery/angioplasty/angina/unexplained fainting?*

Yes

Have you had other cardiac conditions, including heart murmur or irregular heartbeat?*

Yes

Do you have high blood pressure, even if being treated with medication? If yes, list BP with date from last doctor’s visit below.*

Yes

Have you had a bone/muscle/joint injury?*

Yes

Do you have neck/back/knee/shoulder/ankle problems?*

Yes

Have you had frostbite/circulatory problems/heat stroke?*

Yes

Do you have bleeding disorders or anemia?*

Yes

Are you pregnant? If yes, please indicate which trimester below.*

Yes

Do you smoke?*

Yes

Do you have asthma or other respiratory problems?*

Yes

IF PARTICIPANT IS UNDER 18 YEARS OLD, PLEASE COMPLETE THE FOLLOWING:

Has the participant had counseling with a psychiatrist/psychologist/counselor within the past two years?

Yes

If yes, is it currently ongoing?

Yes

Additional Emergency Contact (Other than parent or guardian listed on Page 1):

Name

First Last

Relationship

Daytime Phone

Evening Phone

ALL PARTICIPANTS

If any of the boxes above were checked yes, please provide a description including history, symptoms, hospitalizations, current status and any restrictions. Please refer to the number listed by the issue above, and attach additional pages as necessary. Be sure to detail any medications on Page 1.

Are there any physical or medical conditions not listed above which may affect or limit participation?*

Yes

If yes, please explain

PLEASE READ CAREFULLY:

Please review this form to be certain you have completed every question. This complete medical form is required for participation in this ADK program.

All information on this form is confidential. It is possible to complete many ADK programs with a variety of medical/psychological difficulties, but ADK must be aware of these conditions. Failure to disclose medical and health history information as requested could result in serious harm to you and participants in your program.

The status of your participation will be determined after review of this form. In some cases further evaluation, possibly including consultation with your health care provider, may be necessary.

Print Participant's Name*

First Last

Today's Date*

Month

Day

Year

Print Guardian's Name (if applicant is under 18 years old)

First Last

Today's Date

Month

Day

Year

Digital Signature*

I consent

Consent is hereby given for the applicant to attend an Adirondack Mountain Club program. Permission is given for ADK staff, volunteers, representatives or contractors to obtain or provide medical care for me/my child, or to transport me/my child to a medical facility. I further authorize ADK staff, volunteers, or other medical personnel to render such treatment they consider necessary for my/my child’s health and I agree to pay all costs associated with that care and transportation. I have read and understand both sides of this medical form and the information I have provided is, to the best of my knowledge, correct and complete.

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ADK Program Release & Medical Information – Youth 12 and Under

ACKNOWLEDGMENT OF RISK

RELEASE OF LIABILITY

PHOTO RELEASE

GENERAL INFORMATION

EMERGENCY CONTACT

INSURANCE COVERAGE

MEDICAL & PHYSICAL INFORMATION

HEALTH HISTORY

IF PARTICIPANT IS UNDER 18 YEARS OLD, PLEASE COMPLETE THE FOLLOWING:

ALL PARTICIPANTS

PLEASE READ CAREFULLY:

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