367 RCS HIGH-RISK ASSESSMENT CHECKLIST You must receive counseling and have this checklist signed by your supervisor before engaging in any extreme sports/high-risk activities. Your Name: __________________________________________________________________ Type of Activity: _________________________________________________________________ Education required/received for activity? YES/NO If yes, list education requirement _____________________________________________________ Is special training required? YES/NO If yes, list training requirement _______________________________________________________ List education and training accomplished: ______________________________________________ Experience level (in years): ________________________________________________________ At what level do you participate? AMATEUR/PROFESSIONAL/OTHER If other, explain: ___ _______________________________________________________________ Are special endorsements required? YES/NO If yes, list the endorsement authority:__________________________________________________ Do you own or rent equipment for the activity? __________________________________________ Is the equipment maintained properly? YES/NO If no, obtain proper equipment before participating in activity! Did you receive proper training on the equipment: YES/NO If yes, list training/documentation: _____________________________________________________ If no, ensure proper training is received before participating in activity! What are the risks involved with your activity? (if more space is needed, continue on back of form) _______________________________________________________________________ _______________________________________________________________________ How does your sport manage/reduce risk? (if more space is needed, continue on back of form) Does your sport involve group participation or individual participation? Does you sport require additional insurance to participate? YES/NO If yes, what type and have you obtained it? ________________________________ What type of safety structure does you sport have? __________________________
By signing below, you and supervisor acknowledge that all items above have been addressed to the satisfaction of the supervisor and that you have taken all reasonable precautions to keep risks to an acceptable level. Note: Prior to signing, consider calling JA for assistance if you have questions concerning line-of-duty issues associated with the high-risk endeavor.
______________________________ Your signature/date
______________________________ Supervisor’s signature/date