• APPLICATION, MEDICAL INFORMATION & RELEASE

    APPLICATION, MEDICAL INFORMATION & RELEASE

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  • Emergency Contact Information:

  • Medical / Insurance Information:

  • 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.
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  • 11176 Peaceful Valley Rd. New Castle, VA 24127, 540-864-6792, Fax:540-864-6800 www.wilderness-adventure.com

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