2007 POLAR Medical/legal release 

I, The under signed, understand that the Pennsylvania Organized Live Action Role-playing organization (Adventure Crew 113) has taken all precautions and reasonable steps to minimize all risks to participants, but is unable to completely guarantee that no injury will come to me. Since the events are mainly conducted outdoors in wilderness areas, there is always the possibility of a slip on rough ground, a fall over obstacles in darkness, or the occurrence of some other unforeseen accident. Further, since I may also be participating in mock battles using padded weapons, there is a risk from other participants. While POLAR is committed to safety at our events, it is not possible to control the actions of individuals.

I understand the risks involved in participating in the event sponsored by the Pennsylvania Organized Live Action Role-playing organization. I shall make no claim of any description against the organization, its members or its officers, or any company doing business with the organization for any loss or damages suffered in the course of participating.

I confirm that I am in good physical health and do not suffer from any physical disabilities unknown to the organization. I agree also to the following restrictions placed upon me by the Pennsylvania Organized Live Action Role-playing organization.

I will not use the padded weapons approved by the organization unless I have first been instructed in their proper use through safety training;

I will not bring or consume alcoholic beverages or illegal drugs during the event;

I will not use any skills taught by the organization for illegal purposes;

Unless I submit a written and signed request stating the opposite, I will allow the organization, for promotional purposes to photograph, film, or videotape me participating in the event;

I will at all times abide by the safety rules of the organization.

Does the participant have any medical conditions that POLAR / Adventure Crew 113 needs to know about to ensure the participant’s safety in the event medical treatment is needed? If yes, please list. Include allergies (include bee stings), adverse reactions to any medical drugs, asthma, diabetes, fainting spells, heart trouble, convulsions, bleeding disorders, any others.

No____

Yes (explain)____________________________________________

______________________________________________________

______________________________________________________


Medical Insurance Information (Plan and Policy Number): _________________________________

Family Doctor: ___________________________

Phone: (___) _____________

In case of emergency contact: (or enter NONE):

Name: __________________________________

Relation: _____________________

Address: ________________________________________

Phone: (___) ________________

This Health history is correct as far as I know, and the person herein has permission to engage in all prescribed activities. In the event I, or the person listed below, cannot be reached in an emergency, I hereby give permission to have 1) Adventure Crew 113 members render first aid, and 2) any physician hospitalize, secure proper anesthesia, or order injection for the under signed.

By my signature, I confirm that I have read this release, and agree to its provisions. I understand that this form affects my legal rights.

_______________________________________ ______________________________________
Signature of participant Signature of parent or legal guardian if under 18

__________________________________ ________________________________
Printed Name Date of Birth

_____________________________________________ ________________________________________
Address Phone Number

_______________________________________ ____________________________________
City/State/Zip Today’s Date
 

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