PARTICIPANT RELEASE OF LIABILITY & MEDICAL REGISTRATION FORM

-- Please fill out ALL information below --

PARTICIPANT RELEASE OF LIABILITY
PERSONAL INFORMATION: Please Fill Out The Information Below

Please pick one that applies to you:

Energy Club Virginia IO Piazza Thomas Circle Sports Club Health Club at the Fairmont Energy Club DC Corporate If Corporate please explain:

By participating in any way with Living4Adventure and Kids4Adventure and its related events and activities; I Acknowledge and agree that: 

1.                  The risk of injury from the adventure activities involved within our programming (caving, hiking, kayaking, paintball, rock climbing & rappelling, scuba diving certification, skydiving, skiing, snowboarding, and whitewater rafting, etc), is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce, the risk of serious injury does exist; and

2.                  I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my participation; and agree to follow all rules, and wear all equipment required.

3.                  I willingly agree to comply with the stated and customary terms and conditions for participation.  If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and notify the nearest official immediately; and,

4.                  I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, hereby release, indemnify, and hold harmless Living4Adventure, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, advertisers, and, the owners, and lessors of the premises used to conduct the event (“Releases”), with respect to any and all injury, disability, death, or loss or damage to person or property, to the fullest extent permitted by law.

Please check here to acknowledge that I understand the information above.

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Medical Registration Form

Emergency Contact:
Relationship to Member:
Phone #
Name Of Physician
Physician Phone #

 

You understand and acknowledge that Living4Adventure, is not making a determination of my physical abilities or level of fitness for any outing; rather, you represent to Living4Adventure and verify that you are physically fit and ready for an outing.

Please check here to acknowledge that I understand.

Verification of Accuracy and Full Disclosure:
You understand and acknowledge that my failure to disclose relevant information may result in harm to myself and others during an outing.  You represent and warrant that you have provided all material(s) and important information to Living4Adventure pertaining to my medical, mental and physical condition in view of my participation.  You agree to notify the Living4Adventure if there is any change in my mental, physical or medical condition prior to my scheduled activity.

Please check here to acknowledge that I understand.

Consent for Medical Treatment
You consent to emergency first aid or medical treatment, which may become necessary during or in connection with my participation on the Living4Adventure outing, and give Living4Adventure and it’s employees my consent to seek this help on my behalf if you are unable.

Please check here to acknowledge that you understand.

Please enter any additional information, comments or questions in the space provided below:

 

Please check here if you would like a Living4Adventure representative to contact you.

 

* * * I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTANDING ITS TERMS. I UNDERSTAND THAT I WILL HAVE TO SIGN A PRINTED VERSION THIS FORM BEFORE GOING ON MY FIRST TRIP AND WILL BE SIGNING FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

(A LIVING 4 ADVENTURE REPRESENTATIVE WILL HAVE A PRINTED VERSION OF THIS FORM FOR YOU TO SIGN BEFORE YOUR FIRST TRIP)

 

Please check here to acknowledge that I understand that I have read this entire document and I understand that you will have to sign a waiver form PRIOR to my first trip or event.