The Great Outdoors Inc.
Peachtree City, GA 678-364-8995


MEDICAL INFORMATION


Print Name_____________________________    Sex________     Age_______     DOB_____________

Please let us know about any medical problems you may have that could be a challenge for you or for other participants who may entrust their safety to you during a course or trip. We ask that you describe (in confidence) any potential medical condition you may have, such as dizzy spells, heart condition, fainting, seizure, severe allergic reactions,   head injuries, broken bones, back painn or any condition that could temporarily incapacitate you. If you have no medical problems, please write "NONE" in the space below. If you are under a doctor's order, please advise your doctor about your intention to participate in an outdoor activity.

Please circle any conditions that apply to you.

Diabetes   Allergies to insects or food   High Blood Press   Back problems   Emphysema   Asthma    Heart problems    Other

Explaun medical conditions here_____________________________________________________________________________________

"I have read and understand the medical policy above and state that the information herein is correct to the best of my ability."

Signature _________________________________________________________ Date ____________

If you are under 18 years of age, a parent/guardian must sign with you.

Signature ______________________________________ Date ______________ Relationship __________________

In case of Emergency, please notify:

Name ___________________________________________________________ Relationship __________________

Day Phone _________________________Evening Phone _______________________

Please be sure this person will be available during the times you will be on your event with The Great Outdoors Inc.. We highly recommend that you have your own personal medical insurance. If you do not, please be aware that the Release and Assumption of Risk puts the financial responsibility for any or all injuries on you and your personal resources. Under age 18 persons must show proof of current insurance coverage.

Insurance Company ________________________________________ Group ID # ___________________________

Name of insured in the case of a minor being covered under a Family policy ________________________________

UNDER AGE PARTICIPANTS

"This serves as a release form for the above person to receive medical attention. I am responsible for their medical care and authorize immediate attention for care. I am responsible for the expense of any care which has to be administered."

Signature _________________________ ____________Relationship _____________________Date ______________

 

RELEASE AND ASSUMPTION OF RISK

I am aware that, during the activities that I am participating in under the arrangements of The Great Outdoors Inc. and its agents or associates, I may be subjecting myself to dangers and hazards which could result in an illness, injury or death. I understand that these activities represent strenuous physical activities presenting risk of bodily injury, illness, fatality, and property damage or loss that could result from equipment failure, being struck by a falling object, falling from a height, or other accident. I recognize that such risks; dangers and hazards may be present at any time during the trip. I also am aware that the definitive medical services or facilities may not be readily available or accessible during some or all of the time in which I am participating in the trip. In the event that I require medical care and I am one hour or more from definitive medical care, I hereby give my consent to allow The Great Outdoors Inc. to administer medical care and or medications to the extent for which they are trained. In consideration of the receipt of full payment or a deposit which is hereby acknowledged as part of full payment for the right to participate in the trip and the associated activities arranged for me by The Great Outdoors Inc., I hereby fully accept all risk of illness or damage resulting from my participation in the trip, regardless of the nature or the cause of the damage or injury. Furthermore, I agree that I will not sue The Great Outdoors Inc. for any damages incurred as a consequence of my participation in the trip, regardless of the nature or cause of the damage or injury. I agree that the foregoing obligation shall be binding upon me personally, as well as upon my heirs, executors and administrators, and for all members of my family, including any minors accompanying me. I have carefully read this agreement and am fully aware that this release of liability and a contract between me and The Great Outdoors Inc. and/or its affiliated organization and I am signing it of my own free will.

NAMES (Please print and sign full name)
If you are under age 18, a parent/guardian must sign for you.

Participant or Parent (sign)___________________________________________Date __________________

Participant or Parent (print) ________________________________________ Date __________________