Healing Wild Registration
May 16-22, 2026 | Lake Tahoe, NV
Name
*
First Name
Last Name
Email Address
*
Confirmation Email
Telephone Number
*
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
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Month
/
Day
Year
Date of Injury
*
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Month
/
Day
Year
Treatment Facility
*
Hospital Name & Location
Dietary Restrictions
T-Shirt Size
*
Please Select
Small
Medium
Large
Extra Large
XXL
XXXL
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Telephone Number
*
Format: (000) 000-0000.
Why do you believe you should be selected for this program AND what would you like to gain from being a part of this experience.
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I understand if I am selected for this program, I must be able to participate in hiking, biking, and kayaking, as well as other outdoor and physical activities. I do not have any limitations for the above activities.
*
I understand
I have a valid Real ID or passport.
*
I agree
Release and Indemnity Agreement - In consideration of the Illinois Fire Safety Alliance (IFSA), a corporation not-for-profit, (“Alliance”) undertaking a program of adventure and related activities believed to be of therapeutic benefit and for the welfare of the participant (hereafter called “PARTICIPANT”), including transportation provided by the IFSA, the undersigned agrees, represents and warrants as follows: It is recognized that the PARTICIPANT’S participation in the Healing Wild program involves risks of bodily injury, property damage or any other loss, and it is agreed that all risks of injury, damage, or loss is assumed by the PARTICIPANT to the maximum extent permitted by applicable law. The PARTICIPANT hereby releases and forever discharges the IFSA, and its members, officers, agents, employees, volunteers, representatives and successors of and from all liability, claims or demands of any nature whatsoever in relation to personal injury or damage to property or any loss resulting from, or related to participation in such program, including attendance at the program, participation in activities therein, overnights, during meals and rest and waiting periods, to the maximum extent permitted by law. The PARTICIPANT further hereby agrees to hold harmless and to indemnify IFSA and any of its members, officers, agents, employees, volunteers, representatives, and successors, against liability, loss, damages or costs, including reasonable attorney’s fees that may be incurred as a result of any such action, claim or demand to the fullest extent that such indemnification is permitted by law. The undersigned does hereby covenant with IFSA that the undersigned will never, at any time, sue the IFSA or any person or entity in any way connected with the IFSA as a result of the undersigned’s participation in the program. I, THE UNDERSIGNED WARRANT AND STATE THAT I HAVE READ AND UNDERSTAND THE RELEASE AND INDEMNITY AGREEMENT, AND COVENANT NOT TO SUE. FURTHERMORE, I UNDERSTAND THAT I WILL NOTBE ALLOWED TO PARTICIPATE IN THE PROGRAM UNLESS I HAVE SIGNED THIS RELEASE.
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I have read the entirety and voluntarily signed this covenant not to sue, assumption of risk release waiver and indemnity agreement.
Signature
*
Date
*
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Month
/
Day
Year
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