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The Legendary Black Water Rafting Co.


Medical Form & Risk Disclosure


Review Privacy Policy

IMPORTANT – PLEASE READ:


The Black Water Rafting Experience takes you into a completely natural cave environment including:

  • darkness
  • uneven terrain
  • water which may be fast flowing, rising, cold, and unsuitable for drinking
  • falling objects

The RISKS are REAL as with any adventure activity. Your guides are trained to explain these to you and to manage the risk.  Please follow their advice.

If you are worried about anything please tell your guides.

 

I understand my tour involves hazards and risks that could cause personal injury, death or damage to property. I have provided accurate information, will follow instructions and acknowledge that I freely participate in this activity. I agree that if I am at all under the influence of alcohol or drugs or if the BWR staff believe my safety and well being might be comprised by participating in the adventure, entry will be refused. 

I Agree

 

First Participants Name

First Name*

Last Name*

Phone*
First Participants Age Acknowledgment*
First Participants Date of Birth*
I certify that I am 16 years of age or older
First Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
First Participants Signature*
Second Participants Name

First Name*

Last Name*
Second Participants Date of Birth*
Second Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Third Participants Name

First Name*

Last Name*
Third Participants Date of Birth*
Third Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Fourth Participants Name

First Name*

Last Name*
Fourth Participants Date of Birth*
Fourth Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Fifth Participants Name

First Name*

Last Name*
Fifth Participants Date of Birth*
Fifth Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Sixth Participants Name

First Name*

Last Name*
Sixth Participants Date of Birth*
Sixth Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Seventh Participants Name

First Name*

Last Name*
Seventh Participants Date of Birth*
Seventh Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Eighth Participants Name

First Name*

Last Name*
Eighth Participants Date of Birth*
Eighth Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Ninth Participants Name

First Name*

Last Name*
Ninth Participants Date of Birth*
Ninth Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Tenth Participants Name

First Name*

Last Name*
Tenth Participants Date of Birth*
Tenth Participants Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Address
Address Line 1:
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:
City:
State/Province:
Zip/Postal:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 16 years of age or older
Parent or Guardian's Information
Do you need to take medication with you?*
No
Yes

If yes, please state required medication

MEDICAL DETAILS

Please indicate with a check if you have dislocated, injured or presently have trouble with:

Head
Neck
Shoulder
Arm
Hand
Heart
Spine/Back
Hip
Knee
Ankle
Foot
Asthma
Diabetes
Epilepsy
Haemophilia
Phobias: Heights
Phobias: Small Spaces
Food Allergies (please list below)
Dietary preferences (please list below)
Other (list below)

Allergies

Dietary preferences/other
Ability/Mobility *
1 Very poor Ability/Mobility
2 Poor Ability/Mobility
3 Average Ability/Mobility
4 Good Ability/Mobility
5 Very good Ability/Mobility
Do you have trouble climbing stairs?*
No
Yes
Do you have trouble walking on uneven terrain?*
No
Yes
Will you be wearing contacts/glasses*
No
Yes, I be wearing contacts/glasses in the cave
Do you have trouble hearing?*
No
Yes, I have trouble hearing
Do you have trouble understanding English/Kiwi?*
No
Yes, I have trouble understanding
Water confidence*
1 Very poor
2 Poor
3 Average
4 Confident
5 Very confident
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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