Parent Name or Guardian
(Only for participants under 18 ):

Emergency Contact
(Different from Parents )

I, the participant (or legal representative), have complete knowledge of the activities involved in the Outward Bound Ecuador course and allow the administration of anesthetics in case of emergency, surgery, hospitalization or any medical treatment that could be required. I agree and assume the responsibility for all the medical costs associated with medical treatment, hospitalization, accident, including evacuation costs. I know that all the information given will be treated confidentially, with exception if is required by a doctor for my treatment or condition (or mi child's). Any error of this information may result in serious accidents or injury. I know and accept that this course will take place in remote areas with long distances to medical facilities, communication, transportation or evacuation. If I (or my child's) arrive to the program with any medical condition or psychological affection not mentioned on the medical form, may result in the incapability to participate on the course. In this case the evacuation costs will come to me and understand that the tuition cost will not be refunded.
Outward Bound Ecuador is responsible of all the required security during the course, such as highly trained instructors on group process facilitation, adventure techniques, wilderness first aid, emergency plans, use of the correct adventure gear that accomplish with security standards established by Outward Bound International. In case of fortuitous accident, I exempt Outward Bound Ecuador of any legal responsibility, and will only be responsible if an instructor or any person of their team does not take the necessary security measures, or acts negligent.

A. Conditions and Symptoms (Please check only the options that apply to you)

C. Are you taking Medication?

D. Hospitalization or emergency

E. Personal Medical History Based on the last two years

F. High Pressure must take a test 6 months prior the starting of the course

High Pressure:
Date of test

G. Personal History Based on the last two years.

Medical History

If yes, please give a brief explanation of your experience:

OUTWARD BOUND PARTICIPANT ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS and RELEASE AND INDEMNITY AGREEMENT

In consideration of the services of Outward Bound Ecuador, and its chartering organization, Outward Bound International and each of its respective agents, employees, officers, directors, trustees, affiliates, representatives, independent contractors, volunteers (including consulting physicians), and all other persons or entities associated with them (collectively referred to as “OB”), participant acknowledges and agrees as follows:

I understand I share the responsibility for my safety. I have no mental or physical problems or limitations that might affect my ability to participate that have not been disclosed to OB in writing. I have had the opportunity to ask questions about the activities and the risks of the program in which I will participate.

I understand and acknowledge that the program(s) in which I will participate has risks and it is impossible to anticipate every activity in which I will engage. The activities in which I may participate will depend on the program and may be physically strenuous. These activities may be instructional, educational, or adventurous and may include but are not limited to: hiking; camping; ropes and/or challenge courses (climbing up or over walls, traversing ropes suspended off the ground, potentially at great heights, swinging or traveling by a cable and pulleys and other such activities); physical problem-solving activities; water activities including swimming; vehicle travel; and community and other service projects. I understand that I may engage in other activities not listed above. Activities may be scheduled or unscheduled, mandatory or optional, supervised or unsupervised. The planned program may be modified for any number of reasons, including convenience, weather, emergencies or unexpected conditions. I have the option to decline to participate in any activity. It is impossible to know or list every risk associated with every activity. The risks I may encounter include but are not limited to: slipping, falling or being struck by objects or persons; improper or malfunctioning equipment; and physical contact with other participants.

I acknowledge that participating in an OB program involves inherent risks and other risks, including some not listed above, that can cause or lead to death, injury, or property damage. Furthermore, access to medical facilities communication, transportation, or evacuation may be subject to delay. I understand that OB cannot assure my safety or eliminate all of these risks. I agree to assume all of the risks of the activities of my OB program.

I release OB from, and agree not to sue OB for, any liability, claim, or expense in any way associated with my participation in the OB program or the use of any equipment or facilities. Neither I nor anyone acting on my behalf will make a claim against OB as a result of any loss, injury, damage or death suffered by me. This release includes any losses caused or alleged to be caused, in whole or in part, by the negligence of OB to the fullest extent allowed by law (but not for gross negligence or willful or wanton conduct) and includes claims for personal injury, property damage, wrongful death, breach of contract, or any other type of suit.

I further agree to defend and indemnify OB (to pay or reimburse OB for money it is required to pay, including attorney’s fees and costs) with respect to any and all claims brought by or on behalf of a family member, a co-participant, or any other person for any claims related my participation in the program.

I agree that the substantive law of [state] governs this document and any dispute or suit I have with OB (regardless of the “conflict of law” rules). Any mediation, suit, or other proceeding must be filed or entered into only in [state]. Any claim for damage to person or property arising from my participation in any of the programs and activities conducted or sponsored by OB, or any controversy involving this agreement shall be resolved by binding arbitration pursuant to the then applicable rules of the American Arbitration Association. I agree to pay all attorney’s fees and costs incurred by OB in defending a claim or suit if the claim or suit is withdrawn or to the extent a court or arbitration determines that OB is not liable for the injury or loss. This document is intended to be interpreted and enforced to the fullest extent allowed by law. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions. In addition, OB has permission to use my photo or image for sale or reproduction in any manner it desires, including advertising or display.

BY SUBMITTING THIS FORM, I AGREE IN ALL TERMS AND CONDITIONS OF OUTWARD BOUND ECUADOR PROGRAMS, AS WELL AS I DECLARE THAT I HAVE CAREFULLY READ, UNDERSTAND AND ACCEPT ALL CONDITIONS DETAILED IN THIS DOCUMENT. I UNDERSTAND THAT I AM SURRENDERING CERTAIN LEGAL RIGHTS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, MY MINOR CHILDREN AND OTHER FAMILY MEMBERS, AND MY HEIRS, EXECUTORS, REPRESENTATIVES, AND ESTATE.