Loading...

Informed Consent/Liability Release

For Certified Trainers

I am aware and understand that by completing this DELTA Facilitator Certification program, I will be certified to facilitate activities in the Northwest College Ropes Course for one (1) year.  If I will be facilitating any persons or entities in carrying out activities or otherwise participating in activities, including this training, on the Northwest College ropes course for my school/organization/program, I may do so while not under contract with DELTA (Dedicated to Experiential Learning Through Adventure) but under contract through my school/organization/program. 

Whether facilitating as a paid employee, or volunteering my time, I willingly and knowingly assume for myself, my heirs, family members, executors, administrators and assigns, all risk of physical injury and emotional upset which may occur to me during or after participating in and aspect of this training and any subsequent activities in which I participate, facilitate or supervise.  I willingly and knowingly assume for myself, my school/organization/program, my heirs, family members, executors and administrators, all risk of physical injury and emotional upset for the students/participants involved in activities which I am facilitating or supervising.  I do for myself and my school/organization/program hereby agree to hold Northwest College, its employees, instructors, facilitators, and agents harmless form any liability, damages, and all costs and expenses, including attorney fees, to defend against such claims, which in any way arise out of ropes course activities which I am facilitating/supervising.  

I Agree

I understand that by executing this agreement, I am releasing Northwest College, its employees, instructors, facilitators or agents from any and all liability and/or claims of any kind, specifically including claims of defective equipment or negligence which may in any way have resulted in, caused or contributed to injuries or death to myself or any student or participant for whom I am responsible or for whom I have agreed to indemnify those persons designated above.

I Agree

First Facilitator Name

First Name*

Middle Name

Last Name*

Phone*
First Facilitator Date of Birth*
First Facilitator Signature*
Second Facilitator Name

First Name*

Middle Name

Last Name*
Second Facilitator Date of Birth*
Third Facilitator Name

First Name*

Middle Name

Last Name*
Third Facilitator Date of Birth*
Fourth Facilitator Name

First Name*

Middle Name

Last Name*
Fourth Facilitator Date of Birth*
Fifth Facilitator Name

First Name*

Middle Name

Last Name*
Fifth Facilitator Date of Birth*
Sixth Facilitator Name

First Name*

Middle Name

Last Name*
Sixth Facilitator Date of Birth*
Seventh Facilitator Name

First Name*

Middle Name

Last Name*
Seventh Facilitator Date of Birth*
Eighth Facilitator Name

First Name*

Middle Name

Last Name*
Eighth Facilitator Date of Birth*
Ninth Facilitator Name

First Name*

Middle Name

Last Name*
Ninth Facilitator Date of Birth*
Tenth Facilitator Name

First Name*

Middle Name

Last Name*
Tenth Facilitator Date of Birth*
Facilitator Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!