Name: *

First Name

Last Name

Birthdate: *

MM

DD

YYYY

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone: *

(###)

###

####

Do you have medical insurance: *

Yes

No

Do you have travel insurance: *

Yes

No

Do you have any physical conditions, which might affect your safety or health on the trip? *

Yes

No

Important Note: We are not medical professionals that are qualified to evaluate your physical, medical, and/or readiness to participate in any Girls Adventure Club trip or activity. If you do have a medical and/or physical condition, please consult with your physician as to whether or not you are able to participate. *

By checking this box, I acknowledge that I have read and understood the information provided and agree to assume full responsibility for my physical and medical readiness to participate in the Girls Adventure Club trip or activity.

I acknowledge and agree to the terms stated above.

Name *

First Name

Last Name

Date: *

MM

DD

YYYY

1. Release of Liability *

I release, indemnify, and discharge The Girls Adventure Club and Elizabeth “Beth” Barth and their agents and assigns (collectively releases) from any and all liability for any injury, death, or damage arising from my or my child(ren)’s participation in The Girls Adventure Club Trips and/or activities.

2. Assumption of Risk *

I understand and expressly assume all risks associated with The Girls Adventure Club activities and/or trips, including but not limited to those related to any activities we do or any conditions such as falling, collisions, weather, equipment failure, wildlife and/or insect encounters, remote locations with limited or no medical care and potential delays in emergency response.

*

I acknowledge that these risks cannot be eliminated without jeopardizing the activities and I accept and assume these risks fully.

3. Medical Condition and Fitness *

I certify that I and my child(ren)/ward(s) are each physically and mentally able to participate in the activities independently and have not been advised otherwise by any health professional. I assume all risks of any injury aggravated by pre-existing medical conditions.

4. Responsibility for Safety. *

I understand that releases are not responsible for ensuring my or my child(ren)’s safety. I acknowledge & understand I am solely responsible for determining my and their fitness to participate and for ensuring our safety during the activities.

5. Marine, Wildlife, Insect & Other Encounters *

I agree to comply with the strict no-touch policy for marine, wildlife & insects, maintaining a safe distance and refraining from any actions that may harm or disturb them, myself or my child(ren).

6. Additional Provisions *

I agree to indemnify and hold harmless Releasees from any costs or legal fees they may incur as a result of my or my child(ren)’s participation and actions.

*

I have adequate health insurance or agree to bear the costs of any injury or damage.

*

I am responsible for my personal belongings.

*

I have the full authority to sign this agreement on behalf of myself and my minor child(ren).

*

I agree that if any portion of this agreement is found to be void or unenforceable, all remaining portions shall remain in full force and effect.

*

I agree to indemnify and hold harmless Releasees from any costs or legal fees they may incur as a result of my or my child(ren)’s participation and actions.

*

I understand I have given up substantial rights by signing this document. I am aware of its legal consequences, and have signed it freely and voluntarily, without any inducement, assurance, or guarantee being made to me. I intend my signature to be a complete and unconditional release of all liability, to the greatest extent allowed by law.

*

I am of sound mind and not under the influence of any substances that may impair my understanding.

Date: *

MM

DD

YYYY

Date:

MM

DD

YYYY