High and Wild Waiver of Liability First name: .............................................................................................................................. Last name: .............................................................................................................................. Occupation: …………………………………………………………………………………………….. Address: ……………………………………………………………………………………………. Email: ……………………………………………………………………………………………. Date of Birth: ............................................................................................................................... Emergency Contact: Name: ................................................................................................................. Phone Number: ................................................................................................... Type Of Course [Circle] Abseiling – Canyoning - Rock climbing - Corporate Training - Bush Walking Date(s) Of Course: …...../…...../........ to …...../......../........ I, please print name ....................................................................................................... hereby acknowledge that: A) The activities in which I choose to participate during a High ‘n Wild Pty Ltd course may include abseiling, bushwalking, canyoning, mountain biking, rock climbing, mountaineering (or other as specified above) which are inherently hazardous activities; and whilst the directors, employees and agents of High ‘n Wild Pty Ltd endeavour to use a high degree of skill in ensuring the safety and welfare of participants, neither the business nor its directors, employees and agents can accept liability for loss, injury or damage sustained by a participant or his/her dependants. B) Neither the business, nor its directors, employees and agents will be liable for loss or damage to any goods, equipment, money or property owned by or in possession of a participant during a High ‘n Wild course. Alcohol Or Drugs I declare that I am not under the influence of alcohol or any other substance which limits or changes my physical or mental abilities. Booking Conditions 1) A full refund is given if trip is cancelled by High ‘n Wild Pty Ltd (i.e. bad weather, bushfires etc.). 2) A part refund will be given if the trip is cancelled by High ‘n Wild Pty Ltd after commencement. 3) No refund if trip is cancelled by customer after commencement Health And Fitness Declaration A) Do you/have you suffered from: a heart condition? Yes / No high blood pressure? Yes / No epilepsy? Yes / No a bronchial disorder? Yes / No asthma? Yes / No diabetes? Yes / No anxiety and/or panic attacks? Yes / No B) In the last five years, have you: suffered any severe injury? Yes / No undergone any surgical operation? Yes / No C) Do you have any known allergies? Yes / No D) Are you taking any medication? Yes / No E) Do you suffer from any other medical condition(s) which might affect your ability to participate in the type of course circled above? Yes / No If you have answered ‘Yes’ to any part of A) to E) above, would you please elaborate? .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... F) How do you rate your health/fitness? [circle] poor fair average good excellent G) Can you swim 100 metres (canyoning trips only) Yes / No Signature: ………………………………………………………………………………..…Date:…../….../…... .