YBL Challenge Course 2025

Waiver/Medical Form

Agreement to Participate / Assumption of Risk and Release

Group Name

Date on Course

Disclosure:

The Asbury University Kentucky Outdoor Institute uses a variety of activities including stretching, warm-ups, games, team-building initiatives, high ropes obstacles, rock climbing, canoeing, rappelling, backpacking, caving, and others to elicit experiential learning and positive recreational experiences. Some of these activities can be physically and/or emotionally demanding. Each of the activities is presented upon a “Challenge by Choice” framework, which means that each participant chooses their own level of participation. It must be understood that although the program has been carefully designed for your group and will be operated by well-trained staff, the risk of injury, disability or death cannot be totally eliminated. These risks include but are not limited to: inclement weather; loss or damage to personal property; accidents resulting from climbing, swinging, jumping, falling, water, exposure, exhaustion, fatigue, or other types of outdoor hazards; the hazards of accidents in a relatively remote place; unforeseeable acts of nature and the emotional effects of being in perceived risk.

Release of Liability:

In consideration of the above disclosure, I freely agree to the above risks and assume those risks on my own behalf. I further agree to release, hold harmless, and indemnify Asbury University, its staff members, volunteers, directors, officers and other employee and/or agents from any claims, demands, or causes of action arising from injury, harm or even death as a result of my participation in Asbury University Kentucky Outdoor Institute activities. I agree not to make any claim or file any lawsuit against Asbury University for injuries or damages related to my participation in activities operated by the Asbury University Kentucky Outdoor Institute. I also agree to abide by the policies and procedures as set forth by the program.

Permission to Use Photographs or Video Recordings:

I give Asbury University the right to use any photographs or video recordings created while I (or my child) participate in Asbury University Kentucky Outdoor Institute activities for publicity and advertising purposes.

Yes

Medical Questions:

1. Do you experience or have you experienced any heart problems or are you taking any heart-related medication?

If yes please describe.

2. Are you taking any medication for pain or for chronic illness?

If yes please describe.

3. Do you have higher-than-average blood pressure?

If yes please describe.

4. Do you experience any:

serious allergic reactions (bees, medications, common foods, plants, chiggers, etc.)

asthma or other respiratory problems

physical condition or limitation (backache, knee, shoulder, neck, etc.)

If you checked any of the above please describe.

5. Do you have any other condition(s) which you think may be aggravated by your participation in the program?

If yes please describe.

NOTE: If the answer to any of the questions above is “Yes,” one of our staff may like to check-in with you about the situation. We are able and willing to adjust the program to fit your needs (within reason).

In case of emergency, contact:

Phone Number(s):

My signature below confirms that I have disclosed to program staff any pertinent medical reasons that may affect my safety or the safety of others during this program. In addition, according to my specific limitations, I agree to retain the right and responsibility to choose and direct my own level of participation

I HAVE READ AND FULLY UNDERSTAND AND AGREE TO THE CONTENTS OF THIS DOCUMENT AND SIGN IT OF MY OWN FREE WILL.

Participant Signature

Name Printed

Date

(For persons under 18 years of age, parent or legal guardian must sign as witness.)

Guardian (Witness)

Date

Asbury University Kentucky Outdoor Institute

1 Macklem Dr, Wilmore KY 40390 (859)858-3511. ext. 2491