WILDERNESS WAY APPLICATION FORM
Name Age Birth Date
Program Desired
Date to Fee
Height Weight Sex
Home Address
Phone E-Mail
Mailing Address
Phone
Previous Outdoor Experience
Swimming Ability
Fees include all equipment except that listed on the personal equipment list and any transportation beyond the staging point for the trip. Fees do not include the cost of personal equipment, spending money, fishing licenses, medical expenses, insurance, restaurant meals, accommodations other than campground fees, or the cost of evacuation from the trip for medical or any other reason.
A deposit of $100 ($200 for trips of more than 25 days) should accompany this application and is non-refundable unless the application is declined. Unless otherwise stated, the balance of the fee is due 30 days before the program is scheduled to begin (45 days if the program is over 25 days in length). Beyond this date no payments will be refunded upon withdrawal unless all available openings can be filled with acceptable full-paying participants. All payments should be made in U.S. funds. Payments made less than 30 days before the start of a program should be by certified check or money order.
Scheduling of trips is dependent upon local conditions, such as forest fire danger, water level on rivers, etc. WILDERNESS WAY reserves the right to reroute, reschedule or cancel any trip should conditions warrant or should there not be a sufficient number of suitably qualified applicants. WILDERNESS WAY reserves the right to decline to accept or retain any applicant at any time.
In making this application I am fully aware of the fact that during the program I may be subject to dangers and hazards which could result in injury, illness or death. I recognize that these risks may be present at any time during the program and are part of a wilderness experience and of life. I affirm that my general health is good, since medical services and facilities may not be accessible during some or all of the program. I fully assume all risks of injury, illness or death and I will obtain and provide health, accident, life and/or liability insurance for myself in any amount which I may consider necessary. I will not hold WILDERNESS WAY or its personnel responsible or liable for injury, illness or death resulting from my participation in the program. I assume these risks for myself and my estate and do so voluntarily.
Signature of Applicant Date
Consenting Signature of Parent or Legal Guardian (if applicant is under legal age)
Date
Please return application with deposit payable (in U.S. funds) to: WILDERNESS WAY
c/o Andrew W. Smyth, P.O. Box 91, Woodstock, NY 12498
WILDERNESS WAY MEDICAL FORM
Name Age Birth Date
Height Weight
Has the participant had any recent illnesses, operations or injuries? If so, give details below.
Are there any special precautions, treatments or medications needed by the participant? If so, specify below.
Are there any areas of emotional or psychological stress which might cause the participant difficulty in the course of the program? If so, discuss below.
Does the participant have any physical anomalies or is there other information which might be useful or necessary if the participant should need medical attention? If so, specify below.
Is the participant allergic to any of the following?
Penicillin Other Drugs (specify)
Tetracycline Foods (specify)
Bee Sting Respiratory Reactions (asthma, etc.)
Other Allergies (specify)
Are there any dietary restrictions (vegetarian, etc.)
Date of most recent physical examination (within one year)
Date of most recent dental examination (within one year)
Date of most recent tetanus shot
Does the participant depend upon glasses for vision? If so, bring an extra pair.
Use back of page or separate sheet of paper for additional information. Please be complete.
(Medical form - P. 2)
Who should be notified in case of serious accident or illness?
Name Relationship
Home Address
Phone
Business Address
Phone
Other Address (vacation, etc.)
Name of Participant’s Physician
Address
Phone
Medical Insurance Information: Please list policy holder, name of policy, certificate number and any other pertinent information.
In case of medical emergency, I hereby give my consent to a physician to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for me. I also agree to be responsible for any expenses incurred.
Signature of Participant
Date
The following should be completed if the participant is under legal age:
In case of medical emergency, I hereby give my consent to a physician to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. I also agree to be responsible for any expenses incurred.
Signature of Parent or Legal Guardian
Date