Tetanus Waiver

I am:*

Participant Name*

First Last

Email*

To receive completion of this form.

Program/Group/School Name*

Dear Parent/Guardian, Based on information provided on the Participant Health Form the participant is not currently immunized against tetanus. It is the policy of Deer Hill Expeditions (DHE), at the recommendation of our physician advisor, that participants have a current tetanus immunization prior to the start of their program. Our risk management program requires us to provide you with the following information regarding the Clostridium tetani infection: A cut, puncture wound, laceration or other wound can lead to a tetanus infection in someone without immunity. The only way to obtain definitive immunity is through vaccination. Spores of the tetanus bacteria, Clostridium tetani, are usually found in the soil but can occur virtually anywhere. If deposited in a wound, the bacteria can produce a toxin that interferes with the nerves involved in muscle control. It can cause severe, painful, uncontrollable muscle spasms, make breathing difficult and, ultimately, threaten life. The incubation period for the disease is from 5 days to 15 weeks, with seven days being the average. There is no definitive way, or laboratory test, to diagnose the disease. Antibiotics may not be a sufficient treatment, as this organism hides in deep places where blood circulates poorly. Participants and parent(s) of minor participants agree: I/We have read the above statement regarding the tetanus infection. Due to the inability to accurately diagnose a possible tetanus infection in a non-immunized person in the backcountry, suspect wounds and/or infections may be regarded as a positive diagnosis. At the sole discretion of the Deer Hill field leader, my child may be evacuated from the backcountry for medical attention, which may eventually result in his/her removal from the program and return home. I agree to pay all costs associated with that care and transportation, including, but not limited to transportation, lodging, and other expenses incurred by Deer Hill staff in the evacuation and treatment of my child. In the event of a suspect tetanus contamination and evacuation, I authorize Deer Hill staff or representatives to transport my child to a medical facility for treatment that medical professionals consider necessary for my child’s health. In all cases, regardless of the treatment decisions and actions taken by the Deer Hill staff, and any subsequent contraction of a tetanus infection, Deer Hill, its agents or employees are not responsible or liable for the injury, suffering, or death of me/my child. Deer Hill staff are not to be held negligent, at any level, due to my/our prior decision not to vaccinate for the tetanus infection.

We have carefully read, understand and voluntarily sign this Document, acknowledging that it shall be effective and binding upon me, my minor children, spouse and other family members, and my heirs, executors, representatives and estate. One or both parent(s) must sign below if participant is under 18 years of age.

Name of Participant*

First Last

Date*

Signature*

Name of Parent

First Last

Date

Signature

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