YOUR FULL NAME

Your ADDRESS, STATE.ZIP CODE

TEXAS TODAYS DATE 014CITY WHERE YOU LIVE

Your signature

PARENTS PRINTED NAME

PARENT SIGNATURE

Your printed name

Your ADDRESS, STATE.ZIP CODE

RHS, JCLC, TX

YOUR FULL NAME

PRINT THE WORDS “ NO EXCEPTIONS”

CIRCLE ONE (LIST MEDICATION, IF ANY)

CIRCLE ONE (LIST MEDICATION, IF ANY)

YOUR FULL NAME

YOUR SIGNATURE

PARENTS FULL NAME (CON’T) YOUR FULL NAME

PARENTS SIGNATURE

PRINT PARENTS FULL NAME

PRINT PARENTS FULL NAME

PRINT YOUR FULL LAST NAME, FIRST NAME, MIDDLE INITIAL

PRINT PARENTS FULL NAME

PRINT THE NAME OF YOUR HIGH SCHOOL

PRINT YOUR PARENT/GAURDIAN FULL NAME AND ADDRESS

PRINT YOUR PARENT/GAURDIAN TELEPHONE NUMBER

PRINT YOUR DOCTOR’S FULL NAME AND ADDRESS (IF NONE WRITE NONE)

PRINT YOUR DOCTOR’S TELEPHONE NUMBER

PRINT YOUR DOCTOR’S FULL NAME AND ADDRESS (IF NONE WRITE NONE)

PRINT YOUR DENTIST’S TELEPHONE NUMBER

PRINT RELATIVE/FRIEND/NEIGHBOR/ FULL NAME AND ADDRESS

PRINT RELATIVE/FRIEND NEIGHBOR PHONE NUMBER

READ STATEMENT BELOW AND INITIAL

READ STATEMENT BELOW AND INITIAL

PRINT THE LETTERS “ N/A” (OR PRINT CONDITION , IF ANY)

PRINT THE LETTERS “ N/A” (OR PRINT MEDICATION , IF ANY)

PRINT THE LETTERS “ N/A” (OR PRINT MEDICINES STUDENT IS ALLERGIC TO, IF ANY)

READ STATEMENT AND CIRCLE ONE

CADET SIGNATURE PARENT SIGNATURE

PHYSICIAN STATEMENT OF MEDICAL CLEARANCE      

, is medically cleared to participate in JCLC during                   (Print Cadet’s Name) the period of        /        / 2014 to       /      /2014, for the  Richland High School JROTC.                  (MONTH/DAY)                  (MONTH/DAY)                                       (Name of School) The patient is not precluded physical activity due to _______________________________

                                         (Condition/ medication/allergies)_____________________________________________.  To the best of my knowledge,______________________________________________                                                                                       Print Cadet’s NameIs (other than stated above) in good physical condition. Participation in JCLC, in my opinion, will not have an adverse effect on his/her health and well-being. (If cadet has taken a recent physical, attach physical with clearance, in lieu of completing this form.)     

  ____________Print Type/ Name of Doctor Address/Office/Clinic  

Signature of Doctor                               Date Phone

Revised 01/11

THE LEADING EDGE CHALLENGE COURSE PARTICIPANT AGREEMENT

(Including assumption of risks, and agreements of release and indemnity)

All persons (including minors) using the Challenge Course must sign this agreement to participate. Parents (or legal guardians – both referred to as “Parent”) of minor participants must also sign, to reflect their understandings and agreements, for themselves and on behalf of the minor. Please complete the front and the back of this document (including medical information) and return it to the Lead Facilitator or Challenge Course Manager.

In consideration of being allowed to participate in a Challenge Course program to be organized and conducted by Leadership On The Move, LLC (“LOTM"), the undersigned Participant and, if appropriate, Parent, acknowledges and agrees as follows: The Challenge Course program involves a variety of activities including: warm-ups, games, group initiatives, low and high challenge course elements, and other rigorous adventure activities in a wooded outdoor setting, subject to the sometimes unpredictable forces of nature. The program exposes participants to certain risks, some of which are inherent to the activity – that is, without them the program would lose its value and appeal. Other risks exist, of course. I /we understand that, although measures have been taken in an attempt to manage the inherent and other risks of the program, participants may suffer physical injury and property loss and, in extraordinary cases, emotional trauma and even death. I/we have read or have otherwise been provided a description of the activities and risks of The Leading Edge Challenge Course program at Stony Ranch and understand those descriptions. I/we understand further that participation in the program and its activities is voluntary and no one will be required to participate unless he or she freely chooses to do so. The undersigned Participant, if an adult, or Parent (parent, for himself or herself AND on behalf of the minor child participant) acknowledges and assumes all the risks of the program, inherent or otherwise and whether or not described above. If the participant is a minor, Parent has discussed the risks with the child, who understands them and wishes to participate in spite of them, as evidenced by his or her signature below. Participant, if an adult, or Parent (parent, for himself or herself AND on behalf of the minor child participant) hereby releases and agrees to indemnify (that is, to protect and pay damages and costs, including attorneys fees) LOTM, it's officers, directors, employees, faculty, agents, members, and all other persons assisting in instructing, facilitating and conducting these activities (the “released parties”), with respect to all claims and liabilities of any nature, including claims of negligence, for property loss or damage and for personal injury and death, suffered by Participant or Parent arising in whole or part from participant’s enrollment or participation in the program. Participant, if an adult, or parent, if Participant is a minor, agree further as follows: Understanding that parts of the Challenge Course may be physically or emotionally demanding, Participant or Parent affirms that Participant is in good health and is not under a physician’s care for any condition not disclosed to LOTM in writing which might cause Participant to be a danger to himself or herself or to others. Participant or parent agree that any dispute with LOTM, if not otherwise resolved, will be submitted to mediation in Denton County, Texas; and that any suit filed by Participant or Parent will be filed only in Denton County and governed by the laws of the State of Texas (not including those laws which may apply the laws of another jurisdiction.)

Participant, or Parent, agree to pay all costs including attorneys fees incurred by a released party in defending a claim or suit if that claim is withdrawn or to the extent a court or arbitration determines that the released party is not responsible for the loss claimed by Participant or Parent.

If a portion of this agreement is deemed by a court of competent jurisdiction to be not enforceable, the remaining provisions of the agreement shall nevertheless remain in full force and effect. DATE BIRTHDATE PARTICIPANT (print name) ADDRESS CITY ZIP SIGNATURE (All participants MUST sign, whether an adult or minor) PARENT OR GUARDIAN ________ (IF APPLICANT IS UNDER 18 YEARS OF AGE) WITNESS SIGNATURE (SOMEONE MUST WITNESS YOUR SIGNATURE)

PLEASE COMPLETE BACK PAGE

TODAYS DATE CADETS BIRTH DATE

PRINT CADETS FULL NAME

PRINT CADET’S ADDRESS PRINT CADET’S CITYPRINT CADET’S ZIP CODE

CADET’S SIGNATUREPARENT OR GAURDIAN SIGNATURE

RELEASE / WAIVER (continued)

MEDICAL INFORMATION

I understand participating in any physical activity may be dangerous. Because the inherent and other dangers of the Challenge Course Program activities may be enlarged by pre-existing medical conditions, and to assist the LOTM staff in identifying possible medical issues during an activity, we ask that the Participant, or the Parent of a minor participant, on behalf of that minor, provide the following medical information: Please Initial if Not Applicable I am currently under a doctor's care for:________________________________ _______ _______________________________________________________________ I am currently taking the following medication(s):_________________________ _______ _______________________________________________________________ I am allergic to the following medication(s) or allergen(s):___________________ _______ _______________________________________________________________ The following medical condition(s) might effect my participation _____________ _______ _______________________________________________________________ I, _________________________________, hereby consent to first aid, emergency medical care and, if necessary, admission to an accredited hospital when necessary for executing such care, for treatment of injuries that I sustain while participating in any activity associated with The Leading Edge Challenge Course. Signature: ____________________________________________ Date: ___________________ Physician’s Name: _____________________________________ Phone: __________________ If I am the Parent of a participating minor child, I agree that, if I cannot be reached in an EMERGENCY, the staff of LOTM may transport, hospitalize and otherwise secure medical treatment for my minor child for any injuries that might be sustain while participating in any activity associated with The Leading Edge Challenge Course. Signature:________________________________________ Date:_________________ (Parent or Guardian’s signature) Parent/Guardian:___________________________________ Date:_________________ (Please Print) Phone No. where parent or guardian can be reached in case of an emergency (____) ___________ PHYSICIAN’S NAME ___________________________________ PHONE (___)_______________ (PLEASE PRINT) ***Photos may or may not be taken during your event by Leadership On The Move, please let us know if you do not wish to be photographed. LOTM may or may not use photos for promotional or marketing endeavors.

PRINT DISEASE/CONDITION

PRINT PARENT INITIALS IF NO DISEASE/CONDITION

PRINT MEDICATION

PRINT PARENT INITIALS IF NO MEDICATION

PRINT PARENT INITIALS IF NO MEDICATION OR ALLERGY

PRINT PARENT INITIALS IF NO DISEASE/CONDITION

PRINT MEDICATIONOR ALLERGY

PRINT CADET FULL NAME

SIGN CADET FULL NAME

PRINT DOCTORS NAME

TODAYS DATEDOCTORS PHONE NUMBER

SIGN PARENTS FULL NAME TODAYS DATE

PRINT PARENT FULL NAME TODAYS DATE

EMERGENCY PHONE NUMBER

PRINT DOCTORS NAME DOCTORS PHONE NUMBER