Misawa Outdoor Adventure Program Assumption ofRisk, Hold Harmless, and Indemnity FormI,
hereby WAIVE, RELEASE AND HOLD HARMLESSThe United States Air Force, its agents and employees, and any other person connected formally or
informally with the Misawa Outdoor Recreation Program as chaperon, trip leader, or otherwise theirrespective heirs, personal representatives, successors and assigns from any and all claims for injuries
or damages or otherwise which may arise from any reason whatsoever as a result of my participation
or my child’s participation in the said Outdoor Recreation Program FOREVER.
I, on behalf of myself and (if applicable) my child, acknowledge that I AM RESPONSIBLE for thecondition of my own personal well-being, health, and equipment. Personal effects are MY sole
responsibility. I further acknowledge thatis a dangerous sport or activity and various injuries may occur including, but not limited to, cuts,scrapes, bruises, traumatic injuries, and death. I further understand that events out of the control of
the Outdoor Recreation Program may unwillingly create these situations and therefore HOLD
HARMLESS and INDEMNIFY any and all of the aforementioned entities FOREVER.
In the event of storm, inclement weather, acts of God, vehicle malfunction, equipment malfunction,breakdown, strikes, work stoppages, or other causes or events beyond the control of the United States
Air Force, its agents and employees, I shall pay and be responsible for all costs, charges, andexpenses arising out of but not limited to charges imposed by carriers, lodging management,
destination area, equipment rental stores, or otherwise.
I know that growth of vegetation, debris of various types, and many other hazards or obstacles,
marked or unmarked, exist within the area(s) of this particular activity/trip: I assume the dangers
involved and WAIVE any right to hold liable the United States Air Force, its agents and employeesof any liability whatsoever for the conditions or events that may unfold due to those conditions, atthe area(s) involved FOREVER.
I am further made aware that it is my responsibility to inform the Outdoor Adventure Guide(s) of anyand all conditions, physical or otherwise, that might limit my abilities during trips and programs that
may include, but are not limited to, physically demanding exercise or movement, water activity,
heights, fine motor skills, and mentally and emotionally stressful situations.
Failure to do so, could limit the ability for productive patient care in the event of anaccident/incident. I am also fully aware that advanced medical care could be hours away based ontrip locations.
Moreover, I have provided emergency contact information on the reverse of this form. Emergency
contacts must include individuals that are not a participant in the same trip.
I have read the above and agree to the conditions stated.
(Signature)(Signature of Parent or Guardian if Minor)(Date)(Date)

Misawa Outdoor Adventure Program Assumption of Risk, Hold
Harmless, and Indemnity Form
Trip/ Event Name:

Trip/ Event Date:

Terms:INDEMNIFY – The act of agreeing to secure another against an anticipated loss or damage.
WAIVE - To abandon or forsake a right.
RELEASE - The giving or discharging of a right of action which a person has or may claim against another.
HOLD HARMLESS - In a contract, a promise by one party not to hold the other party responsible if the other party
carries out the contract in a way that causes damage to the first party.

Participant Contact Information
Name:
Phone Number: ________________________ Email Address: __________________________
Local Emergency Contact Information (Unit Leadership, Supervisor, 1st Sgt, Etc.)
Name_______________________________ Unit: _________ Relationship: _______________
Phone Number: ________________________ Email Address: __________________________
Family/Friend Emergency Contact Information (Spouse, Relative, Friend, Etc.)
Name_________________________________________ Relationship: ___________________
Phone Number: ____________________ Secondary Phone Number: _____________________
Medical Information

The information provided is confidential and will not be shared with individuals who are not Misawa
Outdoor Recreation Staff or Medical Professionals. It will be kept in accordance with the Privacy Act
Statement, Misawa Outdoor Adventure Program, provided for your review. Medical information will help
us to better prepare for our adventure and prevent any unnecessary problems.

1. Do you have any history of allergies or anaphylactic reactions? (please circle) YES NO
If yes, please explain.
2. Do you have any history of asthma? (please circle) YES NO
If yes, do you carry an inhaler with you? (please circle) YES NO
3. Do you have any history of diabetes or hypoglycemia? (please circle) YES NO
If yes, do you carry insulin with you? (please circle) YES NO4. Do you have any history of heart disease or high blood pressure? (please circle) YES NO
Pertinent Medical History:

Please list any other medical conditions, dietary restrictions, injuries, or other limiting factors which ourstaff should be aware of, and may affect your ability to safely perform the proposed activity:“I hereby certify that I do not have any know medical conditions that may interfere with myability to safely perform the activity or activities of”(Signature)(Signature of Parent or Guardian if Minor)(Date)(Date)