EVENT WAIVER
What's Your Adventure? LLC
Event Name
*
Event Starting Date
*
-
Month
-
Day
Year
Date
Event Ending Date
-
Month
-
Day
Year
Date
Personal & Contact Information
Name
*
First Name
Last Name
Age
*
Example: 23
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Emergency Contact 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Medical Information
If there is any health conditions we would need to know? If yes, please explain
*
Astma, diabetes, allergies, medications
Is there any activity restrictions?
*
Yes
No
Other
If yes, Please explain
Health Insurance
Do you have any health insurance?
*
Yes
No
Insurance Company
*
Policy Number
Policy Holder
Release
I, undersigned, agree with the following statements
*
Medical Release: Between starting and ending of the event, as deemed necessary,I authorize activity holder to select the hospital or dentist for hospitalization, to secure proper treatment, and/or order an injection, anesthesia, or surgery, for the person specified above.
Liability Release: Even with the best of planning and precaution, unforeseen events can occur. By signing this form, I agree to assume and accept all risks and hazards inherent in the activities. They also agree not to hold activity holder or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: