RR PNW Backpacking Registration

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Your E-mail*

example@example.com

Your Phone Number*

Emergency Contact Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Emergency Contact Relationship to You

Who is your medical insurance provider?

Medical Insurance ID and/or Group Number

Is this your first time backpacking?*

YesNo

If No, can you tell us about your experience with backpacking?

If Yes, can you tell us a little about your current fitness level and activities?

Do you have any medical issues or conditions we need to be aware of?

Do you have any allergies we need to know about?

Are you taking any medication(s)? OTC or prescribed:

Do you have any current injuries we need to be aware of?

Do you have any fears or phobias that could impact you on this trip (ie: fear of heights, animals etc)?

There could be potentially harmful or life-threatening elements outside of our control, such as water crossings, poisonous plants, extreme weather or encounters with wild life. Are you comfortable/competent handling these situations should they occur?

Is there anything we need to know about you that could be a barrier to you being present and enjoying yourself?

What drew you to this retreat? What are you hoping to experience during our time together?

Legal Considerations and Agreements

I agree to follow the guidelines, rules, and policies of the organization. I acknowledge that my photo may be taken or be part of promotional materials that will be used for marketing, promotion, and advertisements. I acknowledge that when I ride in any vehichle other than my own to the event, that I am releasing the drive of all responsibility and assume any and all risk to myself or my property. For medical emergencies, I allow any medical interventions deemed necessary by my hike leader or group members. This includes transportation to the emergency room or hospital even if it is out of network with my insurance. I release this organization from any and all liability from accident or injury should it occur during the organization related events.

I understand that my payment is refundable only until July 3 2023, afterwhich I am forefeit any amount paid. I understand that I can use any non-refundable amount toward sessions with Kim Ludeman Coaching LLC.

RELEASE OF LIABILITY AND ASSUMPTION OF RISK

The individual named above (referred to as “I” or “me” below) desires to participate in the organized group hiking activity which may include urban hikes, snowshoeing, cross country skiing and backpack hiking (the “Activity”) provided by Kim Ludeman Coaching LLC and Reveal Retreats, an Oregon limited liability company with offices located at 1495 NE Cooper Lane Estacada, OR 97023 and 8305 SE Monterey Ave. Happy Valley, OR 97086 (the “Company”). In consideration of being permitted by the Company to participate in the Activity and paying a lesser fee and in recognition of the Company’s reliance hereon, I agree to all the terms and conditions set forth in this instrument (this “Release”).

I AM AWARE AND UNDERSTAND THAT THE ACTIVITY IS A POTENTIALLY DANGEROUS ACTIVITY AND INVOLVES THE RISK OF SERIOUS INJURY, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE. I ACKNOWLEDGE THAT ANY INJURIES THAT I SUSTAIN MAY RESULT FROM OR BE COMPOUNDED BY THE ACTIONS, OMISSIONS, OR NEGLIGENCE OF THE COMPANY, INCLUDING NEGLIGENT EMERGENCY RESPONSE OR RESCUE OPERATIONS OF THE COMPANY. NOTWITHSTANDING THE RISK, I ACKNOWLEDGE THAT I AM VOLUNTARILY PARTICIPATING IN THE ACTIVITY WITH KNOWLEDGE OF THE DANGER INVOLVED AND HEREBY AGREE TO ACCEPT AND ASSUME ANY AND ALL RISKS OF INJURY, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE ARISING FROM MY PARTICIPATION IN THE ACTIVITY, WHETHER CAUSED BY THE ORDINARY NEGLIGENCE OF THE COMPANY OR OTHERWISE.

I hereby expressly waive and release any and all claims, now known or hereafter known, against the Company, and its officers, directors, manager(s), employees, agents, affiliates, owners, successors, and assigns (collectively, “Releasees”), on account of injury, disability, death, or property damage arising out of or attributable to my participation in the Activity, whether arising out of the ordinary negligence of the Company or any Releasees. I covenant not to make or bring any such claim against the Company or any other Releasee, and forever release and discharge the Company and all other Releasees from liability under such claims. This waiver and release does not extend to claims for gross negligence, willfulmisconduct, or any other liabilities that Oregon law does not permit to be released by agreement.

I shall defend, indemnify, and hold harmless the Company and all other Releasees against any and all losses, damages, liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorney fees, fees, the costs of enforcing any right to indemnification under this Release, arising out or resulting from any claim of a third party related to my participation in the Activity, including any claim related to my own negligence or the ordinary negligence of the Company.

I hereby consent to receive medical treatment deemed necessary if I am injured or require medical attention during my participation in the Activity. I understand and agree that I am solely responsible for all costs related to such medical treatment and any related medical transportation and/or evacuation. I hereby release, forever discharge, and hold harmless the Company from any claim based on such treatment or other medical services. I also give Company permission to use my picture in or on any form of advertisement or publication on behalf of Company. I consent to my likeness being used, without compensation, in photos and video in all media, whether now known or hereafter devised. Company reserves the right to use any photos taken on site for promotional purposes. I understand that personal photography is allowed; however, I may not use any of the photos/videos taken on-site for commercial purposes unless I request and receive express written permission from Company.

This Release constitutes the sole and entire agreement of the Company and me with respect to the subject matter contained herein and supersedes all prior and contemporaneous understandings, agreements, representations, and warranties, both written and oral, with respect to such subject matter. If any term or provision of this Release is invalid, illegal, or unenforceable in any jurisdiction, such invalidity, illegality, or unenforceability shall not affect any other term or provision of this Release or invalidate or render unenforceable such term or provision in any other jurisdiction. This Release is binding on and shall inure to the benefit of the Company and me and their respective successors and assigns. All matters arising out of or relating to this Release shall be governed by and construed in accordance with the internal laws of the State of Oregon without giving effect to any choice or conflict of law provision or rule (whether of the State of Oregon or any other jurisdiction). Any claim or cause of action arising under this Release may be brought only in the federal and state courts located in Clackamas County, Oregon and I hereby consent to the exclusive jurisdiction of such courts.

DO NOT SIGN this Release and Waiver form unless you understand and accept the terms stated above.

I understand the risks associated with this trip and release Kim Ludeman Coaching LLC and Reveal Retreats and Employees from liability. My typed signature is legally binding.

Date

My Products

PNW Backpacking Adventure Ticket

$650.00

Total

$0.00

PNW Backpacking Adventure Registration