WII ASSUMPTION OF RISK / LIABILITY RELEASE
Please Print, Read Carefully, Fill Out, Sign and bring with you 

I, __________________________________, (participant) am aware in signing this document for participation in a Wilderness International Inc. activity that certain elements are physically demanding. Furthermore I understand that certain risks and dangers exist in the activities that I may participate in. I acknowledge that while Wilderness International and its staff will make every reasonable effort to minimize exposure to known risks, all hazards and dangers cannot be foreseen. I have personal responsibility to conduct myself in a safe manner and ask the staff for assistance if I have any questions or concerns about my own safety.

In consideration of participation in activities with Wilderness International Inc. I hereby personally assume for myself or for my minor child, as the case may be, all risks in connection with this involvement for any injuries or damages which may occur to myself or my child participant and do fully release Wilderness International Inc., its owners, employees, and agents from any and all claims, demands, damages, rights of action, anticipated or unanticipated, resulting from or arising out of the participants commencement of the activity or use facilities, equipment, and property of Wilderness International Inc. except in the case of Wilderness International’s sole negligence. I also do for myself or for my minor child, as the case may be, agree to indemnify and hold harmless Wilderness International Inc. and it’s affiliates and the employees and agents thereof from any liability and expense for personal or property damages or injury not caused solely by their negligent actions.

I understand that a photographer may be present to photograph the activities at the work project I am signing up to participate in and that I may be photographed while participating in the work project. I agree that I will contact the photographer if I do not wish to be photographed.

I hereby grant Wilderness International Inc., and its directors, the irrevocable and unrestricted right to use and publish photographs of me, or photos in which I may be included. I hereby release Photographer and his/her legal representatives, and Wilderness International Inc. from all claims and liability relating to any such photographs.

My signature on this document is also intended to bind my successors, heirs, representatives, administrators and assigns.

Participant Name: _____________________________________________ Age: ________  Sex: M / F

Street Address:_____________________________________________________________ 

City: ____________________________________ State: ___________ Zip: ______________ 

Phone: ______________________________

Signature of Participant or Parent / Guardian: ____________________________________________

(Parent or Guardian must sign if participant is under 18 years of age)

Emergency Medical Information - In case of emergency, who should be contacted?

Name: _________________________________________ Relationship: _________________________

Primary Phone #: __________________________ Alternate Phone #: ____________________________

Insurance Company: ____________________________________ Policy #: ______________________

We / I authorize the authorities of Wilderness International Inc. to consent to emergency examinations, diagnostic procedures, procurement of medical treatment, emergency surgery, or administration of anesthetics, when in the opinion of any physician or surgeon of good standing such medical treatment is necessary for the mental or physical health of the participant and we / I cannot be reached within a reasonable time to obtain our consent to treatment. This grant of authority shall not create an independent DUTY on the part of Wilderness International’s employees or staff to consent to treatment.

Parent of Guardian must sign this consent form if participant is under 18 years of age

Signature: ___________________________________ dated this _____ day of _____________ 20____

Printed Name: __________________________________

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