THE HERITAGE INSTITUTE
RELEASE FORM
I understand that I am taking this course, voluntarily and although we do no technical
climbing or dangerous activity there is a degree of risk that I understand and accept.
I also understand I am not required to complete any physical activity in order to achieve
course credit and I am free to stop or turn back at any point that exceeds my physical ability.
I certify that I have the necessary skills and ability to participate in the activity of this course;
and I assume full responsibility for myself for bodily injury, death and loss of personal property and
expenses thereof as a result of my negligence in participating except to the extent such damage or
injury may be due to the negligence of the operators named below.
I agree to abide by the instructions given to me verbally or in writing by the operators:
ANTIOCH UNIVERSITY SEATTLE, THE HERITAGE INSTITUTE, THE INSTRUCTORS, AND THEIR
EMPLOYEES.
I further understand that the operators above reserve the right to refuse any person to
participate who is judged incapable of meeting the rigors of participation in activities.
I have read, understood, and accepted the terms and conditions stated above and
acknowledge that this agreement shall be effective and binding upon me during the entire period of
my participation in this course.
INSTRUCTOR NAME ____________________________________DATE(S)
COURSE NAME_______________________________________ COURSE #
1._________________________________
16._______________________________
2._________________________________
17._______________________________
3._________________________________
18._______________________________
4._________________________________
19.___________________________________
5._________________________________
20.__________________________________
6._________________________________
21.___________________________________
7._________________________________
22.___________________________________
8._________________________________
23.___________________________________
9._________________________________
24.___________________________________
10.________________________________
25.___________________________________
11.________________________________
26.___________________________________
12.________________________________
27.___________________________________
13.________________________________
28.___________________________________
14.________________________________
29.___________________________________
THI Release Form
Rev 10/11/2011
15.________________________________
THI Release Form
30.___________________________________
Rev 10/11/2011