PLIFort Miley Adventure Challenge Course Statement of Understanding

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					                       PLI/Fort Miley Adventure Challenge Course
                       Statement of Understanding and Legal Release


Group _________________________________________ Course Date ______________

Participant Name______________________________________________Age ________

Street_____________________________________________________Apt #_________

City________________________State ___________Zip Code_____________________

Day Phone _________________________Evening Phone_________________________

This Statement of Understanding and Legal Release covers participation in the Adventure Ropes Course offered by
PLI, Fort Miley. I understand in signing this statement that certain elements of this program are physically
demanding. I should only participate in the Ropes Course if I am free of medical or physical conditions which
might create undue risk to myself or others who depend on me. I hereby state that I am free from such conditions.

I am aware that these activities involve a potential for injury to my person and property. To the extent that I
participate in such activities, I do so voluntarily and assume full responsibility for any loss and/or inconvenience
resulting from my participation. I further agree to indemnify and hold harmless PLI, Fort Miley, the National Park
Service, the San Francisco State University Foundation and each and all of their officers, directors, employees and
agents from any and all liability incurred as a result of my participation. I also agree that this Statement of
Understanding and Legal Release shall serve as a complete legal release and assumption of risk for my heirs,
executors, and administrators, and for all members of my family, including any minors.

I also give my permission for photos and/or video to be taken of me, and agree that PLI may use the photos and/or
videos, without compensation, for marketing purposes.

If any family members and/or other individuals are listed as authorized participants on the above section of this
statement, I hereby declare that I am authorized to sign this Statement of Understanding and Legal Release on their
behalf, and understand and agree that they are bound by all the terms and conditions of this document.



Signature __________________________________________                             Date

This statement of Understanding must be signed by each adult participant and/or guardian of any minor
participants.

                           Next page for Medical Information
Medical Information:
Please indicate any limiting health conditions, allergies, or medications for you and/or your
family members:




Health Plan: _____________________________ Policy Number: __________________


Name of Physician: _______________________________Phone: ___________________


Emergency Contacts:


Name:                                              Relationship:

Day phone:                                         Evening phone:

Name:                                              Relationship:

Day phone:                                         Evening phone:


Optional Information:
Please check your ethnic identity:

__ Korean                                                 __ Asian Indian
__ Filipino                                               __ Cambodian
__ African American                                       __ Laotian
__ Mexican-American, Mexican, Chicano                     __ Vietnamese
__ Central American                                       __ Thai
__ South American                                         __ Other Southeast Asian
__ Cuban                                                  __ Guamanian
__ Puerto Rican                                           __ Samoan
__ Other Latino, Spanish-origin                           __ Other Pacific Islander
__ Chinese                                                __ White
__ Japanese                                               __ Other
__ American Indian or Alaskan native; Tribe_____