IslandWood Release Form (Adult

IslandWood Release Form (Adult-18 years and older)
PLEASE COMPLETE BOTH SIDES OF THIS FORM IN INK
Participant's Name: ___________________________________________________________
School/Group:________________________________________ Program Dates:___________________________
Participant’s Age: _________ Birth Date:_______________________ Gender: : £Female £Male £Other
Address (include city and zip): __________________________________________________________________
Work Phone: ______________ Home Phone: ___________ Cell Phone: ___________ Email: ______________
EMERGENCY CONTACTS:
1) Name: ______________________________________________
_____________________
Day Phone: (____)
Evening Phone: (___) _______________ Pager/Cell: (___) _________________ E-mail: __________________
2) Name: ___________________________________________________ Day Phone: (____) _________________
Evening Phone: (___) _______________ Pager/Cell: (___) _________________ E-mail: __________________
Please read the following carefully before signing:
ACKNOWLEDGEMENT AND RELEASE AUTHORIZATION FOR MEDICAL TREATMENT:
I am familiar with the program for which I, the participant, am registering. I understand that this program involves
activities of a physical nature that will take place in an outdoor environment, and may include hiking on trails and
rough terrain and in the vicinity of bodies of water, overnight camping and walking on high bridges and canopy
walkways. I further understand that there are risks associated with these kinds of activities.
As a condition of participation in this program and/or the use of IslandWood equipment and/or facilities, I agree
that I will be fully responsible for any and all personal injuries, property damage, loss of personal property, or any
other loss that may result from my participation, and I agree not to hold IslandWood responsible, and their
respective agents and employees, to the fullest extent permitted by law, for any damages, liabilities or expenses
that result from participation in this program and/or the use by me, the participant, of any IslandWood facilities
and /or equipment.
If I am taking any medication, I understand that IslandWood will not be responsible for administering such
medication. I hereby give permission to personnel of ISLANDWOOD to authorize any x-rays, tests, procedures,
anesthetic, surgery or treatment on behalf of, and to provide or arrange for any transportation of, me, the
participant, as may be required in the event of an emergency. If the emergency contacts designated previously
cannot be contacted, I hereby give permission to a licensed physician, or other qualified health care provider as
may be appropriate, to administer such treatment to me, the participant, as may be necessary under the
circumstances, including hospitalization.I certify that I have completed the Health History and Health
Questionnaire on the reverse side of this form fully and accurately and accept full responsibility for any errors
or omissions.
MEDIA AUTHORIZATION: I agree that any photographs or videotape taken by any IslandWood personnel of
myself as a program participant shall be the property of IslandWood, and may be used by IslandWood, at its
discretion, for any publicity, education, marketing and/or advertising purposes and I hereby consent to and
authorize such use without restriction.
I HAVE READ THE AGREEMENT, AND FULLY UNDERSTAND IT, AND AGREE TO BE BOUND BY ITS TERMS.
Signature: __________________________________________________
Date: ___________
BE SURE TO COMPLETE THE MEDICAL /DIETARY QUESTIONS ON REVERSE!!!
Physical Condition
Medications
Please list any physical/medical conditions that would be
helpful for us to know in an emergency:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Are you taking any medications? _____yes _____ no
Are you capable of participating in an easy to moderate 3-mile
hike, with frequent rest stops? ____yes ____no
Food Restrictions
Please indicate any dietary restrictions due to preference,
religious practice, lactose intolerance, food sensitivity, etc.
The following are NOT due to a food allergy:
Please circle any that apply:
No meat (vegetarian)
No animal products (vegan)
If so, please list and describe:
Name of Medication
Dosage & Instructions
1)_____________________________________
2)_____________________________________
3)_____________________________________
4)_____________________________________
Allergies
Have you been diagnosed for any food allergies? If yes, please
describe:
_____________________________________
_____________________________________
_____________________________________
Do you carry an epinephrine aut0-injector for these food allergies?
Yes __ No __
No pork
No red meat
No nuts
No dairy
No wheat/gluten
Please name any non-food allergies that you have. (If allergies
are severe, medication must be carried):
_______________________________________
____________________________________________
Other restrictions: ___________________________
____________________________________________
____________________________________________
____________________________________________
Miscellaneous
Health Care
Is there anything else that you believe is important for us to
know in regard to your participation in this program? If so,
please describe:
Name of physician: ___________________________________
Physician’s Telephone: _______________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Is participant covered by any medical insurance? __yes __no
If so:
Carrier: ____________________________________________
Group # ____________________________________________
I.D. # _____________________________________________
Subscriber Name (if different than participant):
____________________________________________________