ODA Medical Form and Informed Consent Acknowledgment
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The purpose of this form is to provide a clear and unambiguous exchange of information between ODA Services LLC DBA One Day
Adventures (ODA) and potential participants. This form assists participants in deciding whether to contract ODA services by
providing information on the inherent risks of ODA activities. This form provides ODA with the required information to assist in
meeting participants adventure and team building needs. Please read carefully the informed consent on both pages, complete the
medical information, and sign.
In consideration of being permitted to participate in ODA activities…
1.) I acknowledge that I have been given the opportunity to participate in a ODA activity and have been advised that I can decline
participation prior, or at selected times, during a ODA activity.
2.) I further acknowledge, assume, and completely understand that the provider (ODA) has no duty to protect me from inherent risks
(listed below) of recreational activities and no corresponding liability to me for injury or loss resulting from those inherent risks.
Inherent risks and dangers in ODA (teambuilding and training) activities include, but are not limited to, running, tripping, colliding, or
crashing into co-participants; falling head or feet first from high structures or obstacles; being lifted, raised, and supported by coparticipants; being struck by play equipment (pool noodles/balls); and unsafe activity set-up or operation by ODA staff.
3.) Inherent risks and hazards in ODA (adventure trip and class) activities include, but are not limited to, falling rocks, flooding,
equipment failure, entrapment, drowning, hypothermia, frostbite, dehydration, heat stroke, muscle cramps, sudden serve weather
changes, illness, improper wilderness course layout, altered wilderness terrain, lightning, and various other acts of nature.
4.) Inherent risks of learning new skills from ODA staff, co-participants, or unguided personal experience can intensify the above risks
and create new risks through personal or instructional challenge, learning incorrect skills, or practicing incorrect skills.
5.) Inherent risks of interaction with co-participants during ODA activities can intensify the above risks and create new risks by
negligent co-participants, careless and reckless conduct between co-participants, mistakes or accidents caused by co-participants, and
participants disobeying ODA instructions.
6.) I have decided to voluntarily participate in ODA activities, or segments of an activity, and understand, personally assume, and
acknowledge the inherent risks of participating in all ODA activities (listed above), and I further understand that these activities are
not emotionally or physically safe. Thus, the potential exists for me to experience physical and/or emotional injury which includes,
but is not limited to, depression, anxiety, irritability, sprains, strains, broken bones, lacerations, concussion, paralysis, and death.
7.) I agree to participate in unscheduled activities and follow instructions from every ODA staff member and understand that by not
following instructions ODA is not responsible for any negative ramifications of my disobedient behavior, including injury to myself. I
understand that ODA utilizes a zero tolerance policy pertaining to participant misconduct and ODA reserves the right to refuse or
terminate participation of any person for any reason(s) seem fit by ODA staff. I consent to the use of reasonable force and its inherent
risks dictated by ODA staff if I threaten to use physical aggression, a weapon, or other means to harm other participants or myself.
8.) I understand that no communication devices are available during ODA adventure trip and class activities. I assume and
acknowledge the inherent risks of ODA activities that reside in remote locations where advanced medical assistance maybe hours to
days away.
9.) I understand that ODA utilizes independent contractors to operate ODA adventure trip and class activities and that ODA assumes
no control or responsibility for independent contractors’ instruction, performance, and/or condition of their equipment.
General Information
Name:
Male ( ) Female ( ) Height:
Address:
Phone:
Weight:
Date:
Birth Date:_______________________
Age:
Email:
Health and Accident Insurance Information
Insurance Company:
Policy No:
Parent/Guardian Information (for participants less than 18 years of age)
Mother/Father Guardian:
Phone:
Address:
Fax:
Email:
Emergency Contact: (or secondary contact in the event that a parent can not be reached)
Name:
Phone:
ODA Medical Form and Informed Consent Acknowledgment
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Relationship to participant:
Health Information (Please check the appropriate box)
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Any bad joint
Chronic illness
Asthma
Diabetes
Bad back
Heart Condition
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Bad hips
High blood pressure
Bad knees
Pregnant
Bad shoulder
Shortness of breath
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Broken Bones
Frequent headaches
Heart Condition
ADHD or ADD
School Suspension
Dizziness
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Rebellious
Anxiety
Depression
Irritability
Abusive
Manic
Allergies__________________________________________________________________________________________
Medications________________________________________________________________________________________
Regarding any selected items describe in detail with date and restrictions, if any:
Please list any special needs including those related to health, learning, or physical needs:
10.) To increase personal and group safety, I have honestly reported complete, relevant, and accurate medical information. I
understand that failure to disclose such information, or providing false information, could result in serious harm to co-participants
and/or myself. I, therefore, release, indemnify, and hold harmless ODA for any injuries, personal loss, or death, pertaining to coparticipants or myself that results from my dishonest or absent disclosure.
11.) I acknowledge and understand that if my reported health issue possesses a direct threat to the emotional or physical health and
safety of co-participants, ODA may deny my participation.
12.) I acknowledge that my information provided above is subject to ODA screening and may require further assessment and medical
clearance from a physician prior to participation in ODA activities. ODA medical screening does not ensure medical safety, eliminate
inherent risks of ODA activities, or participants’ health and medical conditions, guarantee an incident-free experience, or ensure
consideration of all participant health issues.
13.) My medical information will be kept confidential except in the case of emergency, which I will agree to the release of medical
and accident information to the sponsoring medical facilities, insurance companies, or agency deemed appropriate, by ODA.
14.) I am not now, nor will I be under the influence of, or consume, any alcohol or any non-prescription substance before or during an
FO activity. ODA staff at no time or under no circumstances will administer prescription drugs or other personal medications.
15.) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify and hold
harmless all rights and claims against ODA Services LLC, its members, employees, instructors, trainers, officers, co-participants, subcontractors, and agents (releasees) in respect to any and all injury, illness, disability, death, or personal loss or damage to person or
property, resulting from assisting, observing, or participating in ODA activities (teambuilding workshops, trainings, adventure
trips/classes), whether caused by gross or personal negligence of the releasees or otherwise.
16.) My signature below indicates I fully agree, understand, and accept every statement on this release of liability, negligence, and
assumption of risk agreement, fully understand its terms, and sign it freely, in sound mind, and voluntarily without any inducement.
Print Full Name
Signature
Date
Signature of Parent or Guardian (if under 18)
Date