required registration forms odyssey b submit …...please write legibly and in pen. please answer...

9
REQUIRED REGISTRATION FORMS - ODYSSEY B SUBMIT THESE FORMS TO OUR OFFICE BY MAIL OR EMAIL WITHIN 14 DAYS OF REGISTRATION I understand that, during my participation on an Adventure WV program, I will be exposed to above normal risks. Although Adventure WV has taken precautions to provide proper organization, supervision, instruction and equipment for each trip, it is impossible for the Adventure WV program to guarantee absolute safety. I acknowledge that all risks cannot be eliminated without destroying the purpose and character of the trip or seminar. Also, I understand that I share the responsibility for safety on the trip and I assume that responsibility. I agree to comply with the instructions and directions of the Adventure WV staff members during the trip. The following describes some, but not all of the risks: WVU Adventure WV programs take place out of doors, where participants are subject to environmental and other risks. Activities include hiking and backpacking, camping, rock climbing, initiatives, challenge course, zip line, caving, and whitewater boating. Activities take place in remote places, far from medical facilities. Communication and transportation are difficult and sometimes evacuations and medical care can be significantly delayed. Equipment may fail or malfunction, despite reasonable maintenance and use. Meals are prepared on gas stoves or fires. Water requires disinfection before use. Camping risks and hazards include burns, cuts, diarrhea and flu-like illness, and falling timber. Travel is by vehicle, raft, on foot and by other means, over rugged unpredictable off-trail terrain, including boulder fields, downed timber, rivers, rapids, river crossings, mountain passes, steep slopes, slippery rocks. Risks include collision, falling, capsizing, drowning and others usually associated with such travel. Environmental risks and hazards include rapidly moving, deep or cold water; insects, snakes, and predators, including large animals; falling and rolling rock; lightning, flash floods, and unpredictable forces of nature, including weather which may change to extreme conditions without notice. Possible injuries and illnesses include hypothermia, frostbite, sunburn, heatstroke, dehydration, and other mild or serious conditions. I am aware that Adventure WV activities include risks of my injury or death. I understand the description above of these risks is not complete and that other unknown or unanticipated risks may result in property loss, injury or death. I agree to assume responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary, no one is forcing me to participate, and I elect to participant in spite of and with knowledge of the inherent risks. I have no physical or psychological problems that would prohibit my participation in the trip. I further understand that West Virginia University will not provide medical or other insurance coverage for this trip. If I must evacuate for any reason, I understand I am personally responsible for all medical/evacuation fees and that I will not receive a refund of the trip fee. (Participant must provide a copy of their medical insurance card prior to participation). In consideration for the opportunity to participate in the activity and to the extent allowed by law, I release West Virginia University and its employees, agents, and volunteers, and waive all claims for personal injury or any other damage which may arise out of or be in any way related to my participation in this activity, including any claim based on actual or alleged negligence, gross negligence, intentional, or reckless behavior. Participant’s Name (Please Print): Student Signature: Date: I (we) acknowledge that there can be no guarantee of absolute safety against risks and unforeseen accident, as detailed above, that West Virginia University will not provide medical or other insurance coverage for this trip, and consent to the participation of the above named individual with the Adventure WV program. Parent/Guardian Name (If participant is under 18 yrs of age - Please print): Parent/Guardian Signature: Date: Phone (304) 293-5221 – [email protected] – adventurewv.wvu.edu 2001 Rec Center Dr., Morgantown, WV 26506-6018 ADVENTURE WV – WEST VIRGINIA UNIVERSITY ACKNOWLEDGEMENT OF RISK AND ASSUMPTION OF RESPONSIBILITY

Upload: others

Post on 02-Aug-2020

6 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

REQUIRED REGISTRATION FORMS - ODYSSEY BSUBMIT THESE FORMS TO OUR OFFICE BY MAIL OR EMAIL WITHIN 14 DAYS OF REGISTRATION

I understand that, during my participation on an Adventure WV program, I will be exposed to above normal risks. Although Adventure WV has taken precautions to provide proper organization, supervision, instruction and equipment for each trip, it is impossible for the Adventure WV program to guarantee absolute safety. I acknowledge that all risks cannot be eliminated without destroying the purpose and character of the trip or seminar. Also, I understand that I share the responsibility for safety on the trip and I assume that responsibility. I agree to comply with the instructions and directions of the Adventure WV staff members during the trip. The following describes some, but not all of the risks:

• WVU Adventure WV programs take place out of doors, where participants are subject to environmental and other risks. Activitiesinclude hiking and backpacking, camping, rock climbing, initiatives, challenge course, zip line, caving, and whitewater boating.

• Activities take place in remote places, far from medical facilities. Communication and transportation are difficult and sometimesevacuations and medical care can be significantly delayed.

• Equipment may fail or malfunction, despite reasonable maintenance and use. Meals are prepared on gas stoves or fires. Waterrequires disinfection before use. Camping risks and hazards include burns, cuts, diarrhea and flu-like illness, and falling timber.

• Travel is by vehicle, raft, on foot and by other means, over rugged unpredictable off-trail terrain, including boulder fields, downedtimber, rivers, rapids, river crossings, mountain passes, steep slopes, slippery rocks. Risks include collision, falling, capsizing,drowning and others usually associated with such travel.

• Environmental risks and hazards include rapidly moving, deep or cold water; insects, snakes, and predators, including largeanimals; falling and rolling rock; lightning, flash floods, and unpredictable forces of nature, including weather which may change toextreme conditions without notice. Possible injuries and illnesses include hypothermia, frostbite, sunburn, heatstroke,dehydration, and other mild or serious conditions.

I am aware that Adventure WV activities include risks of my injury or death. I understand the description above of these risks is not complete and that other unknown or unanticipated risks may result in property loss, injury or death. I agree to assume responsibility for the inherent risks identified herein and those inherent risks not specifically identified. My participation in this activity is purely voluntary, no one is forcing me to participate, and I elect to participant in spite of and with knowledge of the inherent risks.

I have no physical or psychological problems that would prohibit my participation in the trip. I further understand that West Virginia University will not provide medical or other insurance coverage for this trip. If I must evacuate for any reason, I understand I am personally responsible for all medical/evacuation fees and that I will not receive a refund of the trip fee. (Participant must provide a copy of their medical insurance card prior to participation).

In consideration for the opportunity to participate in the activity and to the extent allowed by law, I release West Virginia University and its employees, agents, and volunteers, and waive all claims for personal injury or any other damage which may arise out of or be in any way related to my participation in this activity, including any claim based on actual or alleged negligence, gross negligence, intentional, or reckless behavior.

Participant’s Name (Please Print):

Student Signature: Date:

I (we) acknowledge that there can be no guarantee of absolute safety against risks and unforeseen accident, as detailed above, that West Virginia University will not provide medical or other insurance coverage for this trip, and consent to the participation of the above named individual with the Adventure WV program.

Parent/Guardian Name (If participant is under 18 yrs of age - Please print):

Parent/Guardian Signature: Date:

Phone (304) 293-5221 – [email protected] – adventurewv.wvu.edu 2001 Rec Center Dr., Morgantown, WV 26506-6018

ADVENTURE WV – WEST VIRGINIA UNIVERSITY ACKNOWLEDGEMENT OF RISK AND ASSUMPTION OF RESPONSIBILITY

Page 2: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

REQUIRED REGISTRATION FORMS - ODYSSEY BSUBMIT THESE FORMS TO OUR OFFICE BY MAIL OR EMAIL WITHIN 14 DAYS OF REGISTRATION

Phone (304) 293-5221 – [email protected] – adventurewv.wvu.edu 2001 Rec Center Dr., Morgantown, WV 26506-6018

ADVENTURE WV – WEST VIRGINIA UNIVERSITY COMMITMENT TO EXCELLENCE & MEDIA RELEASE FORM

➢ Please write legibly and in pen.

We are excited you are participating in an Adventure WV program. We work hard to ensure that each AWV program is safe, challenging, and fun. In order to live up to these standards and to provide the best program possible, we additionally have high expectations for all of our participants. We ask you as a participant to be committed to excellence by agreeing to abide by the course conditions, in that you will:

• Be open to meeting new people, try new things, have fun, and challenge yourself

• Be willing to do your best and work hard to complete all activities on your program

• Maintain a positive attitude, even in the face of hardship and difficulties

• Comply with procedures and practices, as outlined by the AWV staff

• Respect and follow the Leave No Trace environmental practices

• Demonstrate appropriate language and behavior toward people and the environment, and leave behind alcohol,tobacco, and/or drugs (abusive behavior or the possession of these items will be cause for expulsion). This is atobacco-free program.

I have read the above information and agree to abide by the rules and standards of Adventure WV programs.

Student Signature: ___________________________________________________ Date: __________________________

COMMITMENT TO EXCELLENCE

For the privilege of participating in activities for West Virginia University, I hereby give my consent for my image andlikeness to be videotaped, audiotaped, or photographed for the following uses:

• Educational/instructional media• Recruitment/outreach media• Development media• Newsworthy media documentation

I further authorize West Virginia University and/or West Virginia University Hospitals, Inc., and their component parts, touse this electronic media and/or photographs in any manner—whole, or in part.

This waiver includes usage of this media in any way deemed appropriate, which may include electronic andphotographical reproductions thereof for the production of educational, instructional, promotional, or institutionaladvancement materials which support the educational and outreach activities of West Virginia University.

I hereby waive any right I may have to inspect or approve any use of this electronic media and/or photographs and Irelease West Virginia University and its component parts from all liability which could result from its use.

Participant’s Name: __________________________________________________________________________________

Student Signature: ___________________________________________________ Date: __________________________

A parent or guardian must sign this form if the model is a minor or if the model is hindered by mental or physical challenges.

Parent/Guardian Name: _______________________________________________________________________________

Parent/Guardian Signature: ____________________________________________ Date: __________________________

MEDIA RECORDING/USAGE RELEASE

Page 3: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

➢ Please write legibly and in pen.➢ Please answer the following questions honestly and accurately. This information will be kept confidential.➢ Our goal is to provide you with the best experience possible, making accommodations where needed.➢ Please contact us for questions or concerns about any of the following items.➢ *Please notify us of any changes that happen between completing this form and the start of your program.*

Last Name: _____________________________________ First Name: ____________________________________

WVU ID#: _________________________ Mix Email: ___________________________________________________

Home Phone: __________________________________________ Cell Phone: ______________________________

Height: ____________ Weight: ___________ Gender: ______________ Date of Birth: ______/______/________

Age: ______________ Dorm Name & Room # (if applicable): ____________________

Street Address _________________________________________ City/State/Zip: ___________________________

PARTICIPANT INFORMATION

Emergency Contact #1: __________________________________________ Relationship: _____________________

Cell Phone: ________________ Home: ________________ Work: ________________ Email: _________________

Emergency Contact #2: __________________________________________ Relationship: _____________________

Cell Phone: ________________ Home: ________________ Work: ________________ Email: _________________

EMERGENCY CONTACT INFORMATION

Each participant is responsible for medical expenses. A copy of your current medical insurance card should be brought along with you on the program.

Name of Insurance Company: _____________________________ Insurance Co. Phone: ______________________

Group #: ______________________________________________ Name on Insurance Card: ___________________

INSURANCE INFORMATION

Do you have any ALLERGIES? ____ YES ____ NO

If YES, do you carry epinephrine, such as an Epi-Pen? ____ YES ____ NO

If YES, Have you ever been hospitalized for these allergies? ____ YES ____ NO

Describe your allergies, including severity and other pertinent information: __________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

ALLERGY INFORMATION

ADVENTURE WV – WEST VIRGINIA UNIVERSITY Participant Information Form

REQUIRED REGISTRATION FORMS - ODYSSEY B SUBMIT THESE FORMS TO OUR OFFICE BY MAIL OR EMAIL WITHIN 14 DAYS OF REGISTRATION

Phone (304) 293-5221 – [email protected] – adventurewv.wvu.edu 2001 Rec Center Dr., Morgantown, WV 26506-6018

Page 4: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

Please mark dietary restrictions, needs, and requests here. If it is not listed on this form, we cannot accommodate it.

Do you have any DIETARY RESTRICTIONS (i.e. vegetarian, lactose-intolerant, etc.)? ____ YES ____ NO

Describe your dietary restrictions, including foods avoided and other pertinent information: ____________________

_______________________________________________________________________________________________

DIETARY INFORMATION

Please list any other pertinent health information that may affect your ability to participate in this program, including recent injuries, pre-existing health conditions, etc. It is also helpful for us to know if you have or are planning on requesting accommodations from WVU Office of Accessibility Services that may also apply to your program: _______________________________________________________________________________________

_______________________________________________________________________________________________

OTHER PERTINENT HEALTH INFORMATION

If you are taking any medication that may be required during the program, you must bring all of those with you. If you do not have them, you may not be allowed to participate in the program. Please list all medications, if not taken, that may affect your ability to participate in the program: ________________

_______________________________________________________________________________________________

MEDICATIONS

If you regularly use any brace, orthotic, or other device, please bring this device with you. If you do not have them, you may not be allowed to participate in the program.

Please list any brace, orthotic, or other device that you use regularly: ______________________________________

_______________________________________________________________________________________________

OTHER

Please bring any vision or hearing corrective items with you. If you wear contacts, please bring glasses in addition.

Do you wear glasses, contacts, hearing aids, or use other implements to correct vision/hearing? ____YES ____NO

VISION/HEARING CORRECTION

Physician’s Name: ____________________________________________ Phone: ____________________________

PHYSICIAN INFORMATION

I have reviewed the AWV Essential Eligibility Criteria online at adventurefirstyear.wvu.edu/essential-eligibility-criteria and certify that I meet the criteria necessary to participate in the activities involved: ____________________ (initial)

I hereby state, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of Participant: ____________________________________________________ Date: _________________

Signature of Parent/Guardian (Required if under 18): _____________________________ Date: ________________

ACCURACY STATEMENT

REQUIRED REGISTRATION FORMS - ODYSSEY B SUBMIT THESE FORMS TO OUR OFFICE BY MAIL OR EMAIL WITHIN 14 DAYS OF REGISTRATION

Phone (304) 293-5221 – [email protected] – adventurewv.wvu.edu 2001 Rec Center Dr., Morgantown, WV 26506-6018

Page 5: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

Note that the following four pages contain two separate third-

party waivers, which are specific for activities associated with

your Odyssey B trip.

• The first waiver is a three page “Via Ferrata Climber

Agreement” for NRocks Outdoor Adventures. While you

must read over all three pages, the ONLY page that you

need to print, complete, and return to Adventure WV

First-Year Trips is page 3.

• The second waiver is a single page “Laurel Highlands

River Tours, Inc.” rafting waiver. You must print,

complete, and return this single page waiver to

Adventure WV First-Year Trips.

You must return these third-party waivers in addition to the

Adventure WV specific forms that precede this page.

Page 6: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

Via Ferrata Climber Agreement (Including Acknowledgement of Risks and Agreements of Release and Indemnity)

This document contains important information about the Via Ferrata at NROCKS Outdoor Adventures (referred to herein as “NROCKS”) and the properties on which it is located. It may affect the legal rights of climbers of the Via Ferrata and their families. It must be read, understood and signed by all Climbers 18 years or older. If a Climber is a minor (under 18 years of age) his or her parent or legal guardian (referred to herein as “Parent”) must sign, for himself or herself and on behalf of the minor child.

In consideration of being allowed to climb the Via Ferrata and to move about its premises, the undersigned adult Climber

and Parent, if applicable, acknowledge and agree as follows:

The Via Ferrata

The Via Ferrata is a hiking and rock climbing route with permanently fixed rungs, cables, and other climbing aids to assist in movement over the vertical rock faces. The Via Ferrata utilizes steel climbing rungs on steeper sections to decrease the difficulty of the climb. The climb is steep and arduous with approximately 900 feet of elevation gain/loss over the approximately three mile hike/climb. The hiking and climbing surfaces are loose, slippery and unstable and will require Climber to use his or her hands in order to maintain balance. At times, Climber is exposed to a potential fall of over 200 feet. The Via Ferrata includes one suspension bridge that has open spaces between the support boards and is 200 feet long and 150 feet above the ground. Climber is required to attach, un-attach and re-attach himself or herself to an accompanying cable or steel rungs by means of a double, or “Y”, lanyard, allowing Climber to remain attached by one leg of the lanyard while re-attaching, by means of the other leg, to a new location on the cable/rungs. The Via Ferrata requires Climber to be alert and demonstrate careful judgment and strict attention to remaining attached to the cables/rungs at all times.

The Via Ferrata experience is designed for use by persons of at least average mobility, strength, physical ability, emotional stability, and in good health. Climber must carefully consider health issues – physical and emotional, including the use of prescription or non-prescription medications – before choosing to participate, and inform Via Ferrata staff, in writing, prior to the beginning of the experience, of any issue which might affect his or her performance on the route. Climber – not Via Ferrata staff – has the responsibility of determining his or her level of fitness and other qualifications, physical and emotional, to participate in the Via Ferrata experience. Climber agrees that he or she will not use, and will not be under the influence of, any recreational drug or alcohol while climbing the Via Ferrata.

Climber understands that he or she must be attentive to instructions and warnings posted at the Via Ferrata registration area and provided by Via Ferrata staff during the hiking and climbing portions of the experience. Failure of Climber to abide by all rules, guidelines and instructions of Via Ferrata staff may, at the sole discretion of the staff, result in the dismissal of Climber from the Via Ferrata climb without refund of any fee or other expense paid.

Ris

ks

The risks of the Via Ferrata and hiking to and from the climbing site, include, among others, rockfall (including rocks dislodged by other climbers), slips, falls, and jolts at the end of a lanyard, causing abrupt contact with the rock face, climbing aids or other climbers. Climbing gear may fail, be misfitted or misused. Climbing aids, however permanently affixed they may appear, may fail. Climber is responsible for his or her own safety and if Climber has doubts about his or her ability to manage the risks of the adventure he or she must not climb. Via Ferrata staff cannot, and must not be expected to, be responsible for the actions of Climber. Staff members and participants may make mistakes of judgment and conduct. Climbing the Via Ferrata and hiking to and from it will expose Climber to the unpredictable forces of nature, including, but not limited to, changing weather conditions, high winds, lightning and hail. Climber may come in contact with plants and insects that create hazards, including allergic reactions, and a variety of wild animals including, but not limited to, deer, snakes, bear, bobcat, and skunks. The Via Ferrata experience occurs in a remote location where radio and telephone communication is unpredictable and medical care and evacuation may be significantly delayed. These risks are inherent in the Via Ferrata experience; that is, they cannot be eliminated without destroying the unique character of the experience. These and other risks may result in injuries and illnesses, including pinches, scrapes, twists bruises, sprains, lacerations, fractures and other physical and emotional trauma, and in extreme circumstances even death.

Assumption of Risks. I, adult Climber or Parent of a minor Climber, have read and understand the information above, and have

viewed images and received additional information at the registration counter and/or on the web site of the Via Ferrata,

(www.NROCKS.com)

I understand that the above description of risks of the Via Ferrata is not complete and that these and other, including unknown or unanticipated, risks, inherent and otherwise, may result in loss or property, injury or death. If I am a Parent of a minor Climber I have

Page 7: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

Wild West Virginia Outdoor Adventures LLC / NROCKS Outdoor Adventures 2 Via Ferrata Climber Agreement

discussed the activities and their risks and possible outcomes with my child, and he or she wishes to participate nevertheless.

I expressly and voluntarily agree to accept and assume all of the risks of enrollment and participation in the Via Ferrata experience and related activities, and moving about the premises of the experience, whether or not described above and inherent or otherwise.

Release. I, adult Climber or Parent of a minor Climber (Parent, for myself and, to the fullest extent allowed by law, on behalf of

my minor child), hereby voluntarily release Wild West Virginia Outdoor Adventures LLC, doing business as NROCKS Outdoor

Adventures, and Fun & Dreams West LLC, and their respective owners, members, officers, directors and staff (“Released Parties”) from any and all claims, demands or causes of action, which are in any way related to my, or the minor child’s, enrollment or

participation in the Via Ferrata experience, including the tour, and the use of Via Ferrata equipment, vehicles, structures, and

adjoining premises. This release includes claims of negligence of a Released Party and to the fullest extent allowed by the laws of

West Virginia, claims of aggravated forms of negligence, and other careless or wrongful conduct of a Released Party.

Indemnity. I, adult Climber or Parent of a minor Climber, agree further to indemnify (that is defend and protect, and pay or

reimburse) the Released Parties and each of them from any claim, by whomever it might be brought, including the minor child,

other participants and members of my, or the minor child’s, family, arising from my, or the child’s enrollment or participation in the Via Ferrata experience, including the tour, and the use of Via Ferrata premises, equipment, vehicles and structures. This indemnity

includes losses suffered by me, or the child, and losses caused by me or the child. This indemnity includes claims of negligence of a

Released Party and to the fullest extent allowed by the laws of West Virginia, claims of aggravated forms of negligence, and other

careless or wrongful conduct of a Released Party. Should a Released Party or anyone acting on his or her behalf incur attorney’s fees and costs to enforce this agreement or otherwise defend a claim, I agree to indemnify and hold them harmless for and pay or

reimburse all such fees and costs to the extent such a claim is withdrawn or relief is not granted on the claim by a court of competent

jurisdiction.

Other. I, adult Climber or Parent of a minor Climber, further agree: a. I have adequate insurance to cover any injury or damage I, or the minor Climber, may cause or suffer while participating in

the activities at the Via Ferrata or moving about the premises.b. In the event that I, the child or anyone on my or the child’s behalf files a lawsuit files a lawsuit against a Released Party, I

agree that the venue of any such suit shall be Pendleton County, West Virginia. I further agree that the substantive laws ofWest Virginia shall apply in the action without regard to the conflict of law rules of that state.

c. I have had sufficient opportunity to read this entire document. I have read and understood it and I agree to be bound by itsterms. I intend it to be binding on me, members of my family, my heirs and estate.

d. I hereby authorize Wild West Virginia Outdoor Adventures LLC to utilize any photo/video or any other media containingimages/sounds of myself, or of my child, for promotional or other purposes, without compensation.

e. If any part of this document is deemed unenforceable by a court of competent jurisdiction, the remaining provisions will

nevertheless remain in full force and effect.

Page 8: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

Wild West Virginia Outdoor Adventures LLC / NROCKS Outdoor Adventures 3 Via Ferrata Climber Agreement

Medical Information. I, adult Climber or Parent of a minor Climber, understand that participating in the Via Ferrata experience is a

strenuous activity. Obesity, high blood pressure, cardiac and coronary artery disease, pulmonary problems, diabetes, asthma, allergies, seizure disorders, pregnancy, arthritis, tendonitis and other joint and muscular-skeletal problems, recent surgery and other

medical issues – physical and emotional (such as fear of heights) – will increase the inherent risks of the experience and cause

Climber to be a danger to himself or herself and to others. It is with this understanding that I have listed below my, or the minor

Climber’s, medical conditions pertinent to the Via Ferrata experience.

If Climber is a female, I acknowledge that participating in the Via Ferrata is not recommended for women who are pregnant and that I am not, or the minor Climber is not, pregnant at this time.

Climber, adult or minor, is taking the following medications: (If none, indicate none)

Climber, adult or minor, has the following medical conditions which might affect his or her participation in the Via Ferrata climb: (If none, indicate none)

I have truthfully completed the medical and special needs information called for above. NROCKS Outdoor Adventures staff is authorized to provide or obtain emergency medical care for me, or my child, and to exchange pertinent medical information with a third party medical care giver.

Participant’s Name (printed): Date:

Adult Participant’s Signature:

Address:

City: State: Zip:

Email:

In case of emergency contact: Phone:

Relation to Participant:

Participant’s Age (if under 18): Participant’s Birth date (if under 18):

If Participant is less than 18 years of age, Parent must also sign.

Minor’s Name (printed): Date:

Parent/Guardian Name (printed): Parent/Guardian Signature:

Address:

City: State: Zip:

Email:

Page 9: REQUIRED REGISTRATION FORMS ODYSSEY B SUBMIT …...Please write legibly and in pen. Please answer the following questions honestly and accurately. This information will be kept confidential

Signature of Participant If under the age of 18, Parent or Legal Guardian

Agreement to participate and affirmation of liability release forLOWER YOUGHIOGHENY

Form 01-5/12

Today’s Date NN - NN - NN Rally Time NN : NNLast Name NNNNNNNNNNNNNNNNNNFirst Name NNNNNNNNNNNNNNNNNNPresent Address NNNNNNNNNNNNNNNNNN Apt. NNNCity NNNNNNNNNNNNN State NNZip NNNNN - NNNN

_______________________________________________________ _______________________________________________

E-mail:______________________________________________________ Do you want to receive email specials? Yes____ No____

Is this a new address since your last visit? Yes ❒ No ❒ Date of Birth__________/_________/__________

Phone__________________________________________

LAUREL HIGHLANDS RIVER TOURS, INC.

In consideration of Laurel Highlands River Tours, Inc. and Laurel Highlands Rentals, Inc. (“Laurel Highlands”) furnishing services and/or equipment to enable me to participate in outdoor activities, I agree as follows: All outdoor activities by their very nature provide a physical and mental challenge to an active participant. The individual participates largely based on his or her own stamina and strength. I fully understand and acknowledge that all outdoor recreational activities, including but not limited to rafting, swimming, canoeing, hiking and bicycling, have: (a) inherent risks, dangers and hazards which exist in my use of outdoor activity equipment and my participation in outdoor activities, (b) my participation in such outdoor activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability; (c) these risk and dangers may be caused by the alleged negligence, recklessness, or gross negligence of the owners, employees, officers or agents of Laurel Highlands River Tours, Inc. and/or Laurel Highlands Rentals, Inc., including their equipment, the negligence, recklessness, or gross negligence of the participants, the negligence, recklessness, or gross negli-gence of others, accidents, breaches of contract, failure to render aid, the forces of nature or other causes. Risks and dangers may arise from foreseeable or unforeseeable causes including, but not limited to, guide decision making, including that a guide may misjudge terrain, water, weather, trail , hazards above and below the water and other hazards and dangers that are integral to recreational activities that take place in a wilderness, outdoor or recreational environment; and (d) by my participation in these activities and/or use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages, whether caused in whole or in part by the alleged negligence, reckless-ness, or gross negligence or other conduct of the owners, agents, officers, or employees of Laurel Highlands River Tours, Inc. and/or Laurel Highlands Rentals, Inc., or by any other person. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, forever discharge, hold harmless, defend and indemnify Laurel Highlands River Tours, Inc. and Laurel Highlands Rentals, Inc. and its owners, agents, officers, and employees from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any outdoor activity equipment or my participation in any outdoor activities. I specifically understand that I am forever releasing, discharging and waiving any claims or actions that I may have presently or in the future for the alleged negligent, reckless, and gross negligent acts and/or other conduct by the owners, agents, officers or employees of Laurel Highlands River Tours, Inc. and Laurel Highlands Rentals, Inc. The Venue of any dispute that may arise out of this agreement, or otherwise, between the parties to which Laurel Highlands River Tours, Inc. or Laurel Highlands Rentals, Inc. or its agents is a party, shall be either the Borough of Ohiopyle, Pennsylvania Justice Court or the State Court in Fayette County, Pennsylvania. This Agreement shall be governed by Pennsylvania law without consideration to its Choice of Law provisions. I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT, AGREE IT IS MY INTENTION TO ASSUME THE RISK OF INJURY AND RELIEVE LAUREL HIGHLANDS RIVER TOURS, INC., LAUREL HIGHLANDS RENTALS, INC., ITS AGENTS, EMPLOYEES, AND RELATED ENTITIES FROM ALL MANNER OF LIABILITY INCLUDING LIABILITY FOR PER-SONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY ANY ACTUAL OR ALLEGED NEGLIGENCE, RECKLESSNESS, GROSS NEGLIGENCE, INTENTIONAL ACT OR OMISSION, FRAUD, MISREPRESENTATION OR ANY OTHER CAUSE. Laurel Highlands River Tours, Inc. and Laurel Highlands Rentals, Inc. reserve the right to use any and all photos/videos of you or your group for promotional purposes.

PARTICIPANT ASSUMES ALL RISKS.Advise us of any medical conditions that may affect

your ability to participate in today’s activities.

P.O. Box 107 • Ohiopyle, PA 154701-800-4RAFTIN (472-3846)

email: [email protected]