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PARTICIPANT RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT

***READ BEFORE SIGNING*** 

In consideration of being allowed to participate in any way in the program, related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death.

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF THEY ARISE FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation.

3. I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, IMDEMNIFY, AND HOLD HARMLESS THE KAYAK ACADEMY, INC., Washington State Parks, its officers, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 

October 17, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
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

Emergency Contact's 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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's STUDENT RECORD & RELEASE OF HEALTH INFO
Which class are you signing up for?*

What is the date of your class? *

Height *

Weight *

Shoe size *

Emergency contact *

Emergency contact's relationship to participant *

Occupation (be specific, i.e retired engineer) *

How did you hear about the course? *

Any prior kayak lessons? (please describe) *
Have you practiced capsizing a kayak and the wet exit?*
No
Yes

Have you ever succeeded in kayak rolling? If yes, how many years since last one? *
Do you have a paddle preference? *
straight shaft
bent shaft
small shaft
Greenland paddle
no preference
Will you be bringing any of the following?:*
None
Dry suit
Wet suit
Both dry suit and wet suit

If bringing my own kayak, it is a: (Make, model i.e. Tiderace Xceed)
I will bring my own booties or kayak shoes (Note: rubber boots, sandals, and water socks that fall off are not allowed).*
No
Yes
I will bring my own helmet (High Wind, Surf, River, and Tidal Rapids courses only. Select no if you are not in these classes)*
No
Yes

Please list any prescription or non-prescription medications other than birth control. Write N/A, none, etc. if you are not taking any: *
Have you ever had or do you currently have (please check all that apply)...... *
Allergy to bee stings (If yes, obtain a prescription bee sting kit before going on our overnight and longer trips)
Motion sickness (carsick, etc. If prone to motion sickness you may get sea sick in a kayak, bring preventive medications)
Tendonitis or Carpal Tunnel Syndrome
History of recurrent back problems or back surgery
Fear of closed spaces (Claustrophobia)
Fear of water (Aquaphobia)
Asthma or wheezing with breathing or wheezing with exercise
Epilepsy, seizures, convulsions or taking medications to prevent them
None of the above
Have you ever dislocated shoulder?*
No, Never
Yes, Left
Yes, Right
Yes, Both

Do you have any form of diabetes? If yes, please tell us any relevant details. If no, please write N/A, no, etc. *

Do you have and allergies (food and other), dietary preferences or restrictions? If yes, please describe in detail. Otherwise, please write No, N/A, etc. *
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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