Agreement To Participate For Minors Form
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1Howell Conference and Nature Center
Agreement to Participate For Minors
Group/School Name ____________________________________________________________________________________
Name ______________________________________________Age _____Birth Date (Month/Year) ____________________
Address________________________________________City______________________State_________ Zip____________
Parent/Guardian's Names______________________________ _________________________________________________
Home Phone ______________________Work Phone__________________________ Today's Date ____________________
I understand that at the Howell Conference and Nature Center, I am expected to follow all the rules as presented by the
Challenge Program facilitator, Ropes staff, & EE staff including, but not limited to: listening and following safety instructions,
running is not allowed, no negative comments to other participants, respect for adults in charge and other participants, and
positive encouragement given to other participants. I fully realize that participation in the high ropes, low ropes, initiatives,
obstacle, tower, zip line, wall climbing courses ("Courses"),Global Village, and all Environmental Education classes involves
psychologically and physically challenging situations and that my participation in the same could result in injuries including but
not limited to: sprains, cuts, rope burns and/or abrasions or more serious injury. I acknowledge that the Howell Nature Center
("HNC ") has/will informed me of all required safety regulations and that my failure to follow the regulations and instructions
may result in serious injury.
/s____________________________________________________________________________________________________
PARTICIPANT'S SIGNATURE
DATE
I understand that a physician should be consulted before participation in these courses if my child has one of the following
conditions: is pregnant, has a back condition, high blood pressure or a heart condition. I understand that an inhaler for exercised
induced asthma, an Epi-pen for severe insect allergies or any other medication needed for a chronic medical condition should
be brought with my child to the challenge courses. I acknowledge that my child's participation in the Courses means I accept
the dangers that are open, obvious and necessary to these activities.
I agree to hold the Howell Conference and Nature Center and the Presbytery of Detroit, Inc., its sponsors, agents,
representatives, board members, employees, contractors and suppliers harmless for any and all damages which my
child might sustain and suffer in connection with my child's participation in the Courses, programs, and activities at
HNC.
The HNC has my permission to secure emergency care for my child if necessary. I accept full responsibility for the cost of any
treatment for any injury suffered while participating in the Courses. I understand that any photographs taken of my child
participating in the Courses or programs may be used for publicity.
MEDICAL STATEMENT
I recognize that climbing can be a strenuous endeavor requiring my child to be in good physical condition.
I am listing below those conditions my child has that could restrict my child's participation in the Challenge Courses, and
activities while at camp at the HNC.
__________________________
__________________________
______________________________ ___________
Medications currently taking: _________________________ __________________________ _________________________
I further certify that to the best of my knowledge, I attest that I have disclosed all information that could restrict my child’s
participation in this activity.
IF PARTICIPANT IS UNDER EIGHTEEN (18) YEARS OF AGE, SIGNATURE OF BOTH PARENTS IS
REQUESTED IN ADDITION TO PARTICIPANT'S SIGNATURE.
/s____________________________________________________________________________________________________
PARENT/GUARDIAN SIGNATURE IF MINOR IS UNDER EIGHTEEN (18) YEARS OF AGE
DATE
/s____________________________________________________________________________________________________
PARENT/GUARDIAN SIGNATURE IF MINOR IS UNDER EIGHTEEN (18) YEARS OF AGE
DATE
12/17/04 RJM
Howell Conference and Nature Center
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