2019 Adventure Group Registration
Health Statement, Indemnity, Release & Assumption of Risk
"Adventure is not in the guidebooks, and beauty is not on the maps."
Are you signing up a Participant, or are you a Chaperone Participant?
2019 Boys Latin 7th O/N
2019 Brooksfield Farm Day
2019 Del Ray Montessori O/N
2019 DeMatha Leadership O/N
2019 DSRC Pool Kayaking
2019 Evergreen 1st/2nd O/N
2019 Flint Hill 7th O/N
2019 Green Hedges 4th O/N
2019 GS Troop 81378 Kayaking
2019 Holy Redeemer 6th Challenge Course
2019 Holy Redeemer 7th Challenge Course
2019 JDS 7th Splits
2019 Landon 6th-8th Primitive
2019 Lowell Family Campout
2019 Madeira Staff Challenge Course
2019 Patrick Henry 6th O/N
2019 Poolesville HS Cave
2019 Sidwell MS Challenge Course
2019 St Andrews 5th Challenge Course
2019 St. Albans 8th O/N
2019 Stone Ridge 6th O/N
2019 Swanson MS Challenge Course
2019 Wilderness Medicine Canoe
2019 WIS 5th O/N
2019 WIS 6th O/N
Participant Allergies/Health Issues
Relationship to Participant
Parent/Guardian First Name
Parent/Guardian Last Name
Mailing Zip/Postal Code
I acknowledge and agree that myself or my child is participating in a Calleva program. I fully understand and agree that there is the possibility of an accident or other physical injury and agree to assume the risk of such injury and further agree that Calleva, Inc., shall have no responsibility or liability in the event that I or the minor child for whom I am responsible suffer(s) any injury or harm.
I declare that (I am)/ (the minor child for whom I am responsible is) in good physical health and believe that is able without reservations or limited conditions to physically withstand and cope with the indicated rigors of this program.
If I am an adult Particpant or the Parent of a minor Student I agree, for myself and on behalf of the minor student for whom I sign as follows: I understand and acknowledge that the description above the inherent risks of Calleva's activities is not complete and that other, including unknown or unanticipated, risks, inherent and otherwise, may result in property loss, injury, illness or death. I acknowledge that my participation in this Calleva experience is purely voluntary, and I wish to participate in spite of and with knowledge of the inherent and other risks involved. I acknowledge and assume the inherent risks described above and all other inherent risks of my Calleva activity. In addition, except for an injury or other loss which occurs on lands whose rules or regulations prohibit my doing so as a matter of law, I expressly assume ALL risks of my Calleva activity, inherent or otherwise, and whether or not described above.
AGREEMENT OF RELEASE AND INDEMNITY:
On behalf of myself and any minor child for whom I sign, I hereby release and hold harmless Calleva and its owners, directors, officers, employees, contractors and other agents (each a “Released Party”) from all liabilities, injuries, damage, causes of action, complaints, suits, claims, obligations, costs, losses and all other legal responsibilities (collectively, “Claims”) suffered by me or such minor child and arising from participation in any activity of Calleva unless such Claim is caused by the gross negligence, malice or willful misconduct of the Released Party against whom the Claim is brought. I specifically agree not to institute or cooperate with any Claim in violation of the foregoing sentence. I further agree to indemnify and defend Calleva or any other Released Party against any Claim that may be brought against it by any person if such Claim is attributable to any of my or my minor child’s actions or failure to act, is such actions or failure to act constituted gross negligence, malice or willful misconduct on the party of my child or me.
THE PARTICIPANT HAS READ THIS PAGE AND UNDERSTANDS AND VOLUNTARILY AGREES TO ITS TERMS, WHICH SHALL BE BINDING UPON THEM, THEIR HEIRS, ESTATE, EXECUTORS AND ADMINISTRATORS.
(Check box if Applicable): We hereby allow Calleva to use photographs or images of me/my child for appropriate promotional material related to the activity the participant will be enrolled in.
Participant/Responsible Adult Electronic Signature
Date of Electronic Signature
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