Butler University Challenge Course
	Challenge Course Informed Consent
Risks			Prevention			Solution/Treatment
1) Getting hit by a falling object.			Be alert.  Look up before			Inform staff of injuries for
			walking near or under course.			assistance.
			Wear a helmet.
2) Hair, clothing or jewelry			Have long hair tied back.			If caught, remain calm and ask
getting caught in pulleys or			Remove rings, dangling earrings,			the staff for assistance.
other parts of the challenge			watches, etc., and wear proper
course.			clothing (ie, avoid loose sleeves)
3) Injuries or discomfort caused			Tie harness as secure as possible			If you have any questions or
by improper wearing of harness.			and check for any loosening			doubts, ask the staff for
			thoughout the day.  Have tied			assistance.
			harness checked by two different
			staff members.
4) Scrapes and cuts.			Climb within abilities.  Wear			Inform staff of any injuries.
			proper clothing (ie., long pants
			and long sleeved shirt).
5) Death or serious injury.			Wear proper safety gear.  Check			Inform staff of any injuries.
			to see if carabiners are secure.
			Make sure belayer is ready
			BEFORE you climb.
I have read and understand the risks listed above and how to avoid them and agree to take an active part
to protect myself and my fellow participants during this activity.  I realize there are other risks and/or dangers
that may exist and I will avoid these also, and I will not participate in unsafe practices and I will inform the
staff of any dangers known to me that may cause injury to others or myself.
Furthermore, I agree to respect the rights and feelings of the other participants and staff and to act in a
supportive and caring manner during my participation of the event.
I understand that I have the right to not participate if I don't feel physically or emotionally safe.
I have read all of this Informed Consent and understand that I may be dismissed from participation for
refusing to follow any of the above.
Signed:_________________________________________					Date:  _________________
_______________________________________________					Date:  _________________
(Signature of parent/guardian if under 18 years old)
PLEASE PRINT:
Name: _________________________________________					Date: _________________
Address: _______________________________________					Age:  _________________
							(Revised: 3/19/02)