Liability Form

Type of Workshop

Dates of Workshop

Participant's Name

Email address:

Sex

Male
Female

Date of Birth

Do you have health/accident insurance?

Yes
No

If yes, name and address of company:

Medical Information: This information will be kept in confidence by Moonshadow Services and only shared with your permission.

Do you have any limitations, health disabilities or handicaps (temporary of permanent)?

Yes
No

if yes, please identify and explain:

Are you currently taking medication (prescribed or otherwise. e.g. cold medicine)?

Yes
No

If yes, List medication(s), and what condition it is for:

Do you have any allergies, reactions to medications, any other medical limitations?

Yes
No

If yes, identify and explain

Are you allergic to bee/wasp stings?

Yes
No

Are you allergic to any foods?

Yes
No

If yes, please identify

Do you have any history of heart disease, or heart attack?

Yes
No

Do you have high blood pressure or any history of high blood pressure?

Yes
No

Do you have any of the following symptoms: chest pain/pressure heart palpitations, heart murmur?

Yes
No

Have you ever had a stroke?

Yes
No

Do you have diabetes?

Yes
No

Is there a history of heart disease in your family?

Yes
No

If you circled yes to any of the above 6 quesitons, identify the issue and describe below:

Check the appropriate box: I exercise vigorously (brisk walk pace or faster)

Less than once a week
Once a week on average for twenty minutes
Three times or more per week on average for twenty minutes or more each time.

PARTICIPANT AGREEMENT, RELEASE, AND ACKNOWLEDGEMENT OF RISK

In consideration of the services of Moonshadow Learning Services, Inc., their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “MLS), I hereby agree to release, indemnify, and discharge MLS, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

I acknowledge that my participation in outdoor adventure based activities such as canoeing, ropes or
challenge courses, hiking, camping, backpacking and/or mountain biking entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

The risks include, among other things: Slipping and falling; falling objects; water hazards;
exhaustion; exposure to temperature and weather extremes which could cause hypothermia (heat related illnesses), heat exhaustion), sunburn, dehydration; and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life, equipment failure; and improper lifting or carrying.
Furthermore MLS employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participants’ fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being
used might malfunction.

1. I expressly agree and promise to accept and assume all of the risks existing in this activity. My
participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
2. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless MLS from any and all claims, demands, or causes of action, which are in any way connected with my
participation in this activity or my use of MLSs’ equipment of facilities, including any such claims which allege negligent acts or omissions of MLS.
3. Should M.L.S. or anyone acting on their behalf, be required to incur attorney’s fees and costs to
enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
4. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while
participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I
am willing to assume the risk of any medical or physical condition I may have.
5. In the event that I file a lawsuit against MLS, I agree to do so solely in the state of North Carolina, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that of any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against MLS on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

By checking this box and entering your initals in the field below, you are agreeing to substitute this electronic signaure for your physical signature. If you do not agree to this, please close this page without submitting, download our liability form to complete it manually.

Yes, I understand and agree.

Enter your initials as your electronic signature:

Please enter the date you completed this form

Address:

Phone Number

PARENTS’ OR GUARDIANS ADDITIONAL INDEMNIFICATION (Must be completed for participants under the age of 18) In consideration of the above identified minor (“Minor”) being permitted by MLS to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless MLS from any and all Claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor.

Name of Parent or Guardian

By checking this box and entering your initals in the field below, you are agreeing to substitute this electronic signaure for your physical signature. If you do not agree to this, please close this page without submitting, download our liability form to complete it manually.

Yes, I understand and agree

Enter your initials as your electronic signature

Please enter the date you completed this form