Heartland Retreat Center Waiver

INSTRUCTIONS: Please read this entire form carefully. Each participant and/or their custodial parent/guardian must read, complete, sign and submit this agreement to Heartland so that Heartland receives all completed and signed forms at least one business day before the Event Date. Without an appropriately signed form delivered to Heartland in advance, the individual will not be permitted to participate in the Program.

I have read, and do understand, the Participation Is Voluntary statement accompanying this form. I understand that my/my child’s participation in all activities offered by Heartland Conference Retreat Center (Heartland) is based on the Participation Is Voluntary philosophy. These activities may include, but are not limited to: High Ropes, Zip Line, Paintball, Team Challenge, Group Problem Solving, Archery, Night Hike, Nature Center, Large Group Game, Orienteering, Living History, Wagon Ride, Bird Blind, Climbing Wall and Wilderness Rush. I recognize that the Heartland Activities are designed to utilize experiential and engaging teaching techniques, and that my participation is purely voluntary. At all times I will choose my level of participation in any activity, and I agree to follow all guidelines and instructions as presented.

I do understand that the staff of Heartland have received extensive training, and will work to protect the emotional and physical safety of myself/my child. I understand that participation in Heartland activities in which I/my child have enrolled, may entail certain risks. I elect to participate in spite of these risks.

I do understand that safe participation in Heartland Activities requires reasonably good health, and I certify that I have/my child has no medical, emotional and/or physical conditions which could interfere with my/my child’s safety in this activity/these activities.

I grant to Heartland and all persons acting through them, the rights to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of myself/my child for use in materials they may create.

I have read and do understand and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon my heirs, assigns, personal representatives and estate, and for all members of my family, including minor children.

Therefore, for myself/my child, I knowingly and voluntarily assume all risks involved in my/my child’s participation, and do hereby release and promise to defend, indemnify, and hold harmless, Heartland and its members, trustees, officers, employees, volunteers, independent contractors, and agents from any and all liability, damages, costs and expenses arising out of or relating to bodily or psychological injury, or loss that may occur as a result of participation in Heartland Activities, whether such injury arises out of the negligence of Heartland, myself/my child, or otherwise.

If your event is taking place at Heartland, I hereby give my permission to Heartland, Licensed by the State of Ohio and Morrow County, to secure emergency medical and surgical treatment.

Signature of Participant (Required) *
Signature Custodial Parent/Guardian (Required if participant is a minor)
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