CONFIDENTIAL MEDICAL HISTORY AND MEDICAL AUTHORIZATION

This form typically takes 5-15 minutes to complete and will require your credit card information in order to submit.

*Printable copies of blank forms may be obtained by contacting Discovery Ministries directly.

As you fill out this form, you will have an opportunity to fill out descriptions for the conditions that you have. For each that you experience please describe in the given box:

• What specific symptoms occur
• How long/often symptom/condition lasts
• How you care for symptom/condition
• How symptom/condition restricts your activity, including your ability to run, lift, and climb
• Date of the last occurrence

I covenant and promise to pay for all medical and liability expenses for any bodily injury, rescue, or property damage I may incur while participating in Discovery Ministries activities and for any bodily injury, rescue, or property damage caused to a third party as a result of my participation in Discovery Ministries activities.

     In consideration of the services of Discovery Ministries, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as "DM"), I hereby agree to release, indemnify, and discharge DM, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

     I acknowledge that my participation in outdoor adventure based activities such as camping, caving, backpacking, rock climbing and rappelling, canoeing, challenge course events, group initiatives, and traveling to and from an activity entails known and unanticipated risks which could result in sickness, exposure to infectious/communicable disease, bodily injury, paralysis, death, emotional injury, personal injury, property damage, damage to myself or third parties, and financial damage. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. Furthermore, DM guides/instructors/facilitators have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They might misjudge the weather, the elements, or the terrain. They may give inadequate warnings or instructions, and the equipment being used might malfunction.

     I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

     I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless DM from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity, my use of DM's equipment, or my use of DM's facilities or property, including any such Claims which allege negligent acts or omissions of DM.

     Should DM or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

     I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I have no medical or physical conditions which could interfere with my safety in this activity, or else I am willing to assume -- and bear the costs of -- all risks that may be created, directly or indirectly, by any such condition.

     In the event that I file a lawsuit against DM, I agree to do so solely in the state of Missouri, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

By signing this document, I acknowledge that I have read, understand and agree to the above statement. I understand that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against DM on the basis of any claim from which I have released them herein.  I understand itineraries are subject to daily change due to circumstances.  Activities may be postponed or canceled at the last minute.

I have had sufficient opportunity to read this entire document.  I have read and understood it, and I agree to be bound by its terms.