ADULT PARTICIPANT. A person enrolled in an adult day care center who is functionally impaired (as defined in this section) or 60 years of age or older and not residing in an institutionalized setting (e.g. nursing home, community-based residential facility, etc.)
ADULT PARTICIPANT. ACKNOWLEDGEMENT OF UNDERSTANDING: I, THE ADULT PARTICIPANT HAVE CAREFULLY READ THIS AGREEMENT IN ITS ENTIRETY, HAVE BEEN PROVIDED AN OPPORTUNITY TO ASK QUESTIONS AND CONSIDER THE EFFECTS OF THIS AGREEMENT, AND UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS, INCLUDING MY RIGHT AND THE RIGHTS OF THE RELEASING PARTIES TO XXX FOR DAMAGES IN THE EVENT OF DEATH, INJURY, OR LOSS. I ACKNOWLEDGE THAT I AM VOLUNTARILY SIGNING THIS AGREEMENT, AND INTEND MY SIGNATURE TO BE A COMPLETE WAIVER OF CLAIMS AND RELEASE OF ALL LIABILITY, INCLUDING THAT DUE TO THE INHERENT AND UNANTICIPATED RISKS OF HOUSE OF AIR ACTIVITIES OR THE NEGLIGENCE OF THE PROTECTED PARTIES, TO THE GREATEST EXTENT ALLOWED BY LAWS OF THE STATE OF TEXAS. Name of Adult Participant (Please Print) Signature of Adult Participant Date Emergency Contact Person Relationship Phone Cell PARENT/GUARDIAN of a MINOR PARTICIPANT ACKNOWLEDGEMENT OF UNDERSTANDING: I, THE PARENT/LEGAL GUARDIAN OF THE MINOR LISTED BELOW, HEREBY GRANT MY MINOR CHILD PERMISSION TO PARTICIPATE IN ALL HOUSE OF AIR ACTIVITIES. FURTHER, I, HAVE CAREFULLY READ THIS AGREEMENT IN ITS ENTIRETY, HAVE BEEN PROVIDED AN OPPORTUNITY TO ASK QUESTIONS AND CONSIDER THE EFFECTS OF THIS AGREEMENT, AND UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS, INCLUDING MY RIGHT AND THE RIGHTS OF THE RELEASING PARTIES TO XXX FOR DAMAGES IN THE EVENT OF DEATH, INJURY, OR LOSS. I ACKNOWLEDGE AND AGREE TO BE BOUND BY THIS AGREEMENT ON BEHALF OF MYSELF, MY SPOUSE, THE MINOR CHILD, AND ANY PARTY FILING ON BEHALF OF THE MINOR CHILD. I UNDERSTAND THAT I AM RELEASING MY RIGHT, THE RIGHT OF MY MINOR CHILD, AND THE RIGHTS OF THE RELEASING PARTIES TO XXX FOR DAMAGES IN THE EVENT OF INJURY, DEATH, OR FINANCIAL LOSS. I ACKNOWLEDGE THAT I AM VOLUNTARILY SIGNING THIS AGREEMENT, AND INTEND MY SIGNATURE TO BE A COMPLETE WAIVER OF CLAIMS AND RELEASE OF ALL LIABILITY, INCLUDING THAT DUE TO THE INHERENT AND UNANTICIPATED RISKS OF HOUSE OF AIR ACTIVITIES OR THE NEGLIGENCE OF THE PROTECTED PARTIES, TO THE GREATEST EXTENT ALLOWED BY LAWS OF THE STATE OF TEXAS. ADDITIONALLY, I, THE PARENT/GUARDIAN OF THE MINOR CHILD, ASSERT THAT I HAVE EXPLAINED THE INHERENT RISKS OF HOUSE OF AIR ACTIVITIES TO MY MINOR CHILD AND THAT THE MINOR UNDERSTANDS THIS AGREEMENT AND AGREES TO COMPLY WITH THE SAFETY RULES. THE FOLLOWING SIGNATURE OF THE MINOR IS TO AFFIRM UNDERSTANDING OF THE INHERENT RISKS OF HOUSE OF AIR ACTIVITIES AND AGREEMENT TO COMPLY WITH HOUSE OF AIR RULES AND THE VOLUNTARY ASSUMPTION OF ...
ADULT PARTICIPANT. Print / / Name of Adult Participant / Climber (please print) Date Age Sign / Signature of Adult Participant / Climber Date FOR PARTICIPATION OF MINORS: This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this below named participant, do hereby give permission for my child or xxxx to participate in the activities of Higher Ground, LLC. I have read and understand the above Release of Liability, Waiver of Claims and Indemnity Agreement and on my behalf and on behalf of my child or xxxx, agree to all terms contained therein. I consent and agree not only to release of all releasees, but agree to release and indemnify the releasees from all liabilities incident to my child or xxxx'x involvement in these activities for myself, my heirs, assigns, and next of kin. I represent that I have full authority to sign on behalf of my child or xxxx, realizing this release is binding upon my child or xxxx as well as myself, and agree not to bring any action or lawsuit against Higher Ground, LLC its owners, officers, instructors, agents or employees for any injury or damage. I acknowledge that this participant is capable of participating in Higher Ground, LLC activities and does not suffer from any health problems that would inhibit participation. I acknowledge that I am responsible for any damage to the equipment while in my child's or xxxx'x possession, which includes loss or theft. Print / Name of PARENT or adult legal guardian (please print) Date Sign / Signature of PARENT or adult legal guardian Date Print / / Name of Minor Participant (please print) Date Age EMERGENCY MEDICATION CHECKLIST Has the above named participant (adult or child) been prescribed an emergency medication for allergy, asthma, epilepsy or other condition? Yes OR No If yes, is the medication available and is the participant familiar with it's indications and administration? Yes OR No If emergency medication is not available at the time of the event the participant may not be allowed to participate. Please list Emergency Medications and conditions: Emergency Medication Condition Available Y OR N Y OR N Y OR N
ADULT PARTICIPANT. Acknowledgement of Understanding: I, the Adult PARTICIPANT have read this Agreement and understand that I am giving up substantial rights, including my right to xxx for damages in the event of death, injury, or loss. I acknowledge that I am voluntarily signing this agreement, and intend my signature to be a complete release of all liability, including that due to the INHERENT RISKS of Program or the NEGLIGENCE of the Protected Parties, to the greatest extent allowed by law of the State of Ohio. _ Name of Adult Participant (Please Print) Signature of Adult Participant Date Emergency Contact Person Relationship Phone
