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Adult Waiver

Adult Waiver

Release and Waiver

As a precedent to my participating in the Four Mounds Ropes Course, I, the undersigned, knowing and voluntarily assume any and all risks inherent in participation and agree to abide by all rules and regulations established by: Team Building Blocks, its officers, directors, officials, volunteers, agents or employees, its successors or assigns; Seth Sample, individually; and Four Mounds Foundation, its officers, directors, officials, volunteers, agents or employees, its successors or assigns. I further waive any right to claim against Team Building Blocks, its officers, directors, officials, volunteers, agents or employees, its successors or assigns; Seth Sample, individually; and Four Mounds Foundation, its officers, directors, officials, volunteers, agents or employees for loss of life, bodily injury, property damage and/or loss, or personal loss that may be sustained as a result of my participation.

In addition, I am waiving my right to claim against Team Building Blocks, its officers, directors, officials, volunteers, agents or employees, its successors or assigns; Seth Sample, individually; and Four Mounds Foundation, its officers, directors, officials, volunteers, agents or employees and I am releasing them from any and all liability which may be based on the acts omissions or negligence of Team Building Blocks, its officers, directors, officials, volunteers, agents or employees, its successors or assigns; Seth Sample, individually; and Four Mounds Foundation, its officers, directors, officials, volunteers, agents or employees.

I have no health problems that would interfere with my participation in the Four Mounds activities that I select. I understand that there are inherent risks in Ropes Course activities.

This waiver is valid for the current year and all future years.

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Complete Address
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Phone Number
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Emergency Contact Name
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Emergency Contact Phone Number
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4900 Peru Rd. Dubuque, Iowa 52001

Phone: 563-556-0985

Cell: 563-580-7909