. HelmZar Challenge Course

. Tulsa Public Schools

.  INFORMED CONSENT

Any person using the ROPES Challenge Course must sign an informed consent.  This form must be completed and included in your packet for your application to be considered for acceptance to the "Quest for the Treasure Chest: GPS Style Summer Academy.

WHEREAS, the undersigned (the "Applicant”) wishes to be accepted for participation in a HelmZar CHALLENGE COURSE program (the "Course") to be organized and conducted by Northeastern State University's  "Quest  for the Treasure Chest: GPS Style" Summer Academy sponsored by Northeastern State University on June 9-13, 2008.

And in consideration of TULSA PUBLIC SCHOOL’S and NORTHEASTERN STATE UNIVERSITY'S action in allowing the Applicant to participate in such Course and Academy, the undersigned acknowledges that he Course will necessarily involve participation in exercises which are, by their nature, physically demanding and will subject the Applicant to stress, anxiety, and possible hazards, not all of which can be foreseen.  It is fully understood that the Applicant will be climbing and walking on cables, logs, ladders, walls and beams; at times, forty plus feet above the ground.  Reasonable precautions will be taken to protect the Applicant.

THE UNDERSIGNED assumes all of the ordinary risks normally incidental to the nature of the programs including risks which are not specifically foreseeable.

THE UNDERSIGNED Applicant hereby releases any and all rights or claims for damages against
NORTHEASTERN STATE UNVIERSITY AND TULSA PUBLIC SCHOOL, its faculty, agents and all individuals assisting in instructing and conducting these activities, from all liability of any nature for any and all injuries, loss or damage suffered by Applicant at or in any way connected with these injuries.

THE UNDERSIGNED Applicant hereby releases the use of any photographs or video footage taken on the Course to be used as needed for publicity of the ROPES Challenge Course program.

MEDICAL CHECK, Do any of the following medical conditions apply to the undersigned?
(Please explain if answering yes to any question).

Heart Condition *                             NO____YES________________

Back or Neck Injuries                        NO____YES________________

Allergic Reactions                             NO____YES________________

Knee, Bone or Joint Injuries              NO____YES________________

Epilepsy * Seizures * or asthma         NO____YES________________

Recent Surgeries                              NO____YES________________

Currently taking medications            NO____YES________________

*Applicant must have a medical doctor's written permission to participate if he or she has, but not limited to, any type of mental or physical condition such as heart problems, seizures, neck and back injuries, or taking medications that affect judgment or motor skills.

DOCTOR'S RELEASE In the event of an emergency, I do hereby authorize any x-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist and any hospital service that might be rendered under the general, specific or special consent of the ROPES Challenge Course staff.

EXECUTED THIS _____ DAY OF ____________________2008

APPLICANT (print) _________________________________________AGE _______

SIGNATURE _____________________ WITNESS _____________________________   

PARENT OR GUARDIAN _______________________________ (If Applicant is under 18 years of age)

Emergency Contact Number______________   Cell Phone Number_______________