INFORMED CONSENT: CHALLENGE COURSE
Risks Prevention Treatment
Strains, sprains, dislocations or Climb within abilities Administer proper first aid, inform
broken bones staff of injury for assistance
Blisters, hot spots, soreness Wear properly fitted footwear, clothes Inform staff of the discomfort
and equipment assistance
Frostnip, frostbite, hypothermia Wear proper clothing (gloves, wool Get to a warm area and warm
socks, etc.). Eat and drink proper affected body parts slowly
amounts
Sore muscles Climb slower, carry less weight, take Inform staff of the discomfort for
more breaks assistance
Dehydration Drink plenty of water (a liter every Rest and slowly drink plenty of water
couple of hours)
Scrapes and cuts Climb within abilities. Wear proper Inform staff of any injuries
clothing
Heat exhaustion or heat stroke Wear proper clothing. Rest if you Rest in shaded area, drink plenty of
become too hot. Drink plenty of fluids. If signs of heat stroke are
fluids. evident, seek medical attention.
Getting hit by falling object Be alert. Wear a helmet. Inform staff of injury for assistance
Hair, clothing or jewelry getting Tie back long hair. Remove rings, If caught, remain calm and ask staff
caught in pulleys or other parts of dangling earrings, watches, etc., and for assistance.
challenge course wear proper clothing (i.e. avoid loose
sleeves).
Death or serious injury Wear proper safety gear. Check to Inform staff of any injuries
see if caribiners are secure. Make
sure belayer is ready BEFORE you
climb.
I have read and understand the risks listed above and have received a safety briefing on risks associated with this activity and
how to avoid them. I agree to take an active part to protect myself and my fellow participants during this activity. I realize there
are other risks and/or dangers that may exist and I will avoid these also, and I will not participate in unsafe practices and I will
inform the staff of any dangers known to me that may cause injury to myself or others. I will be on time for all scheduled
meetings and events.
Furthermore, I agree to respect the rights and feelings other participants and staff and to act in a supportive and caring manner
during my participation in this event. I will take care of myself by letting others know what I need. I will try everything that I am
asked to do by staff. I understand I have the right not to participate if I don’t feel physically or emotionally safe. I will follow all
safety guidelines given by staff. I will not 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 will carry my trash out to a suitable trash container.
I agree not to bring a radio/cell phone, beeper on a trip unless I have written permission from the trip leader.
I have read and understand the alcohol/drug use policy defined in the Student Handbook and agree to abide by them.
I have read all of this informed consent and understand that I may be dismissed from participation for refusing to abide by its
contents.
Participant Initials: _______ Parent/Guardian Initials (if Participant under 18):_______
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ASSUMPTION OF RISK AND INSURANCE CERTIFICATION
Many recreational activities and outdoor adventure programs involve substantial risks of bodily injury or death, property damage,
and other dangers associated with participation in such activities. Dangers related to such activities include, but are not limited
to: hypothermia, broken bones, strains, sprains, bruises, drowning, concussions, heart attacks, and heat exhaustion.
Each participant in these activities should realize that there are risks and dangers inherent in them, and also in the training for,
participation in, and travel to and from such activities. It is the sole responsibility of each participant to participate only in those
activities for which he or she has the prerequisite skills, qualifications, preparations, and training.
The undersigned acknowledges that SUNY Adirondack does not warrant or guarantee in any respect the safety or health of any
individual participant in any outdoor program or recreational activity.
I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage
sustained through my participation in such voluntary outdoor programs or recreational activities, and that I am solely responsible
for maintaining adequate health and accident insurance coverage for such costs.
I accept and assume all risks, hazards, and dangers involved in such activities in which I may elect to participate including the
training, preparation for, and travel to and from the site of such activities or programs.
RELEASE, WAIVER OF LIABILITY, AND COVENANT NOT TO SUE
The undersigned hereby acknowledges that participation in outdoor adventure programs and recreational activities involves an
inherent risk of physical injury and assumes all such risks. The undersigned hereby agrees that for the sole consideration of
SUNY Adirondack (the “Institution”) allowing the undersigned to participate in voluntary recreational programs or outdoor
activities in connection there with, and making available to the undersigned for his or her use while participating in such
programs or activities, certain equipment, facilities, grounds, or personnel of the Institution, the undersigned participant does
hereby waive liability, release and forever discharge SUNY Adirondack and the Board of Regents of the State University of New
York, its members individually, its officers, agents, or employees from any and all demands, rights, and causes of action of
whatever kind or nature, arising out of all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to
property, and the consequences thereof, including death, resulting from my voluntary participation in or in any way connected
with such outdoor programs and recreational activities.
I further covenant and agree that for the sole consideration stated above I will not sue SUNY Adirondack, the Board of Regents
of the State University of New York, its members individually, its officers, agents, or employees for any claim for damages arising
or growing out of my voluntary participation in recreational programs or outdoor activities.
I understand that the acceptance of this Release, Waiver of Liability, and Covenant Not to Sue the Institution or the Board of
Regents of the State University of New York or any member, officer, agent or employee thereof, shall not constitute a waiver, in
whole or in part, of sovereign or official immunity by said Board, its members, officers, agents, and employees.
This Release, Waiver of Liability, and Covenant Not to Sue shall remain in effect for as long as I am a participant in outdoor
adventure programs or recreational activities offered by the Institution. Further, I understand that, if I am an employee or student
at the Institution, this Release, Waiver of Liability, and Covenant Not to Sue shall be effective during the entire period of my
enrollment or employment at the Institution.
I certify that I am 18 years of age and suffering under no legal disabilities and that I have carefully read and understand this
notice.
Print Name: __________________________________ Date of Birth: _________________________
Participant Signature: _______________________________ Date: ________________________
Signature of parent/guardian (if Participant is under 18): ___________________________________
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MEDIA RELEASE FORM
I, the undersigned individual, hereby grant SUNY Adirondack specific permission and the
unrestricted right to photograph and/or make a video and/or sound recording of me and to use and
publish images and recordings of me in any manner and medium; to alter the same without
restriction; to copyright the same; and to distribute and/or display the same.
I hereby waive any right that I may have to inspect or approve the finished product or products or
the advertising copy or print matter that may be used in connection therewith or the use to which
it may be applied.
I hereby release and discharge SUNY Adirondack, and all persons acting with the College’s
permission or authority, from any and all claims or liability by virtue of distortion, blurring,
alteration, optical illusion and/or use in composite or digital form whether the same is intentional,
or otherwise, from any claims or liability for libel or invasion of privacy, and for any other claims
or liability that may occur.
Before signing this form, I have read it completely and understand it, and acknowledge that I am
bound as is anyone who succeeds to my responsibilities and rights as my heirs or assigns.
Signature: ________________________________ Date: __________________
Name: ___________________________________ Phone Number: __________
Address: _________________________________________________________
Duration of Permitted Use: _____________ indefinite or through ____________
If minor (under the age of 18), parent or guardian signature is required:
Signature: ________________________________ Date: __________________
Name: ___________________________________
Return the completed, original form to:
SUNY Adirondack
Office of Marketing and Community Relations
640 Bay Road
Queensbury, NY 12804
Revised 09/2013
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For Internal Use Only:
Release Number: _________________________________
Photographer: ____________________________________
Requested by: ________________________________ (Division / Office)
Description of Photo: (Location, Person, Event, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________
AVS_form_Dec 2019