Cortex Epic 2025 Adult Information & Liability Release

APPLICATION, MEDICAL INFORMATION & RELEASE
YOUR GROUP NAME
DATES OF VISIT

MonthDayYear
Date
Full Name:
Email:
Address:
Preferred Pronoun
City
State
Zip
Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Emergency Contact Information:
First Name
Last Name
Home/Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Emergency Contact Email:
example@example.com
Relationship to You
Medical / Insurance Information:
Insurance Provider
Policy or Group #
Phone
Format: (000) 000-0000.
DOES THE APPLICANT HAVE ANY MEDICAL CONDITION WHICH WOULD PRECLUDE HIM OR HER FROM PARTICIPATING IN ANY OF THE OUTDOOR ACTIVITIES LED BY WILDERNESS ADVENTURE AT EAGLE LANDING? If yes, explain and state which activities are prohibited:
ALLERGIES:
How severe is the allergy...does it require treatment with an epi pen?
DIETARY RESTRICTIONS: (Is the dietary restriction an intolerance or a preference?)
Current medications:
Chronic or recurring medical condition that would be helpful for our staff to know about:
Suggestions on health related information for camp personnel
In the event the Applicant is injured, I hereby give permission for the WILDERNESS ADVENTURE AT EAGLE LANDING staff to administer first aid and/or select a physician to hospitalize, secure proper treatment for, and to order injections and/or anesthesia and/or surgery.
I hereby consent to and authorize the use of photographs or video of the Applicant by WILDERNESS ADVENTURE AT EAGLE LANDING for promotional purposes.
I would like the email listed above to be included in future mailings about information and discounts for our Retreat or Adventure Program.
I understand that WILDERNESS ADVENTURE AT EAGLE LANDING'S activities include, without limitation, hiking, backpacking, camping, rock climbing, rappelling, canoeing, kayaking, caving, low ropes, high ropes, mountain biking, climbing wall, and zip line, and I understand the risks and hazards involved in such activities, including, without limitation, rough water conditions, hiking on irregular and steep terrain, the unpredictable forces of nature, accidents or illness in remote places, and vehicle travel. I understand that such activities may be subject to injury. I understand that such injuries may include broken bones, paralysis, or other serious injury or death. Therefore, in consideration of the acceptance of the Applicant into the WILDERNESS ADVENTURE AT EAGLE LANDING program, I, the undersigned, consent to the Applicant's participation in such activities, and to his/her assumption of all of the above risks. I, personally and on the Applicant's behalf, agree to forever waive, discharge, and release for myself and the Applicant, all claims that I and he/she may have against WILDERNESS ADVENTURE AT EAGLE LANDING, INC. and/or its officers, directors, shareholders, and employees, arising out of or resulting from his/her participation in the WILDERNESS ADVENTURE AT EAGLE LANDING program, and I agree to indemnify them from all liability, costs, and expenses incurred in connection with this release. The information provided on this form is true and complete to the best of my knowledge and the Applicant has permission to engage in any or all of WILDERNESS ADVENTURE AT EAGLE LANDING's activities except as noted above.
(signature)
(date)

MonthDayYear
Date
11176 Peaceful Valley Rd. New Castle, VA 24127, 540-864-6792, Fax:540-864-6800 www.wilderness-adventure.com
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APPLICATION, MEDICAL INFORMATION & RELEASE

Emergency Contact Information:

Medical / Insurance Information: