Please Note - These Forms Are To Be Printed, Filled Out and Mailed To Us

In consideration of the services of Wildside Adventures For Women, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “WA4W”), I hereby agree to release, indemnify, and discharge WA4W, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

The risks include, among other things: Slipping and falling; falling objects; water hazards and accidental drowning; exhaustion; exposure to temperature and weather extremes which could cause hypothermia, hyperthermia (heat related illnesses), heat exhaustion), sunburn. dehydration; and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; equipment failure; and improper lifting or carrying.

Furthermore, WA4W employees have difficult jobs to perform. They seek safety, but they are not infallible. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

Signature of Participant______________________________________________ Print Name_____________________________________

Address_________________________________________________________________________________________________________

Phone________________________________________________

Cell Phone____________________________________________

 Date______________________________________________________

In consideration of _________________________________________(print minor’s name) (“Minor”) being permitted by WA4W to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless WA4W from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

Parent or Guardian:________________________________ Print Name:____________________________ Date_______________________

Many of our adventures are strenuous activities. The effects this exertion has on the human body can vary greatly between individuals. Whenever undertaking a trip with a group of people it is vital that the leader is familiar with each person's medical history. This aids the group in taking the proper actions should emergencies arise. Therefore, it is imperative that you be completely thorough in completing this form. If you need more room to explain an answer, please use the back of this form or a separate piece of paper.

Have you ever had:
(if you answer yes to any, please explain)

Allergies? ____

If yes, do you carry an Epipen? ____
Asthma? ____ Numbness? ____
Back pain? ____ Operations? ____
Broken bones? ____ Shortness of breath? ____
Diabetes? ____ Sprained joints? ____
Epilepsy? ____ Do you get cold easily? ____
Frostbite? ____ Are you taking any medications? ____
Heart Disease? ____ Are you currently under a doctor's care? ____
High Blood Pressure? ____ Are you pregnant? ____

Join dislocations? ____ Do you have any condition that might limit your activity? ____

Is there anything else not covered above that you think is pertinent? ______________________________________

The information I have given on this form regarding my medical history is completely thorough. I will notify the trip leader if any changes occur between now and when the trip begins. I certify that the above information is accurate to the best of my knowledge.

Signature _____________________________________

Date signed ___________________________________

Name: _____________________________________________________

Address: ___________________________________________________

Phone #: ___________________________________________________

Name: _________________________ Relationship: _____________________

Phone # (H): ___________________ (W): ____________________ Cell: __________________ Pager: __________________

Address: _____________________________________________________________________________

Insurance Coverage: Each participant is responsible for his/her own medical expenses:

Insurance Company: __________________________ Policy Number: ____________________

Address: _____________________________________ Phone #: ________________________

Physician's Name: _______________________________ Phone #: ______________________

Date of last tetanus shot: ____________________

Allergies: List all allergies including bites, stings, plants, animals, food and medicines.

______________________ __________________ ___________________

______________________ __________________ ___________________

Do you have any medical conditions that would be aggravated by moderate to strenuous outdoor activity, including, but not limited to, hiking on unimproved, rocky trails? ________ Yes ________ No

If yes, please list. Include any medications (over the counter or prescription) that you take and/or carry with you.

Medication (dosage/amount/frequency) Condition Side Effects

___________________________________ ___________________ ________________________