Outdoor Center
Medical Informed
Consent Form

In agreeing to participate in a Georgia College Outdoor Center program, course, or trip, I may take part in adventurous activities.  These activities may include, but are not limited to, land activities such as camping, backpacking, caving, land navigation, rappelling, top rope rock climbing, bouldering, or tree climbing; water activities such as flat water, coastal or white water rafting, canoeing, or kayaking; group development and challenge course activities; vehicle travel; and service projects.

I recognize certain risks and dangers exist in these activities. These risks include, but are not limited to:  loss or damage of personal property; mental or emotional distress; injury or fatality due to tripping, falling from heights, drowning, allergic reactions to foods, flora or insects, exposure to temperature extremes or inclement weather, sun hazards, equipment failure, and vehicle accidents while traveling to and from the activity site.

I have read and understand the risks listed above and agree to take an active part to protect myself and my fellow participants during the activity. I understand that these risks may be minimized by following staff instructions regarding techniques and equipment usage and by asking questions about things that I do not understand.  I also understand that I should participate at a level and a pace that I am physically and emotionally prepared for and to not attempt activities that seem unsafe. I will also inform the staff of any dangers known to me that may cause injury to me or others. If I am injured, I will alert staff to the situation and follow their instructions on how to respond to the problem. Furthermore, I agree to do the following to support a safe, environmentally sound, and effective experience for myself and others:

  • I will be on time for all scheduled meetings and events.
  • I agree to respect the rights and feelings of other participants and staff and to act in a supportive and caring manner during my participation in this event. 
  • I will not participate in activities or use equipment without proper supervision.
  • I understand that I should do nothing that may harm the environment or destroy its natural beauty, so that anyone who follows me may enjoy what nature provides.
  • I agree not to bring a radio, cell phone, or beeper on a trip unless I have written permission from the lead facilitator or course instructor.
  • I will not use alcohol or illegal drugs prior to or during the program. I will use tobacco in a way consistent with program guidelines.

I have read all of this Informed Consent, had the opportunity to ask any questions that I may have, and understand that I may be dismissed from participation for refusing to abide by its contents.

Consent

I do hereby consent and agree to allow the Outdoor Center at Georgia College the use of my image or likeness in photographs, videos, or audio for educational purposes or promotional purposes, including posting on the Internet. I agree that the use herein may be without compensation to me or my child.

Consent Statement*

Program Information

Program Date*

Participant Information

Please enter your name
Please enter the your email
Please enter your phone number
Date of Birth*
Please enter your date of birth
Address*
Is the Participant Under 18?*
Please enter your parent's or guardians name
Please enter the your parent's or guardians email
Please enter your parent's or guardian's phone number

Emergency Contact Information

Please enter your emergency contact's name
Please enter the your emergency contact's phone number
Please enter your emergency contact's relationship

Medical Information and Authorization for Emergency Medical Care

We hope to minimize the potential for medically related emergencies by obtaining some basic and pertinent medical information from each participant. If you check any of the “yes” boxes on this form, it does not necessarily mean you will not be allowed to participate. You can expect a staff person to speak with you about your condition, how it might be affected by participating in the program, and subsequent options you might have. All information provided on this form will be reviewed by the Outdoor Center at Georgia College and/or GCSU medical advisors, but will otherwise remain confidential, unless you agree otherwise.

1. Have you experienced an asthma attack at any time in your life?*
2. Have you ever been diagnosed with type I or type II diabetes?*
3. Have you ever visited a medical professional for a serious allergic reaction or been given a shot of epinephrine for an allergy or anaphylaxis?*
4. Have you ever received medical treatment for angina, a heart attack, any type of heart disorder/disease, or high blood pressure?*
5. Have you ever seen a medical professional following a seizure, or are you currently being treated for any type of seizure disorder?*
6. Have you had broken bones or joint injuries that cause recurring problems?*
7. Are you currently pregnant?*
8. Have you been diagnosed with any other medical condition?*
Are you participating in a water-based program*
Please rate your swimming ability.*

I am aware of my past and present health and fitness for doing strenuous activity.  I will participate in all program activities, except for those noted on this form by myself and/or my physician.  Information about any and all prescription drugs that I am currently taking is noted on this form.  I have completed this form to the best of my ability with full knowledge that any information withheld may increase the potential for serious injury or reinjury. Should an accident or emergency occur that renders me unable to communicate, I hereby give permission to the physician selected by the Outdoor Center to hospitalize and/or secure proper treatment for me, except as noted on this form. The Outdoor Center at Georgia College reserves the right to limit participation in its programs based on information submitted on this form.

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