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**CLICK HERE FOR PRINTABLE PDF

 

 

PLEASE PRINT OUT THIS FORM, FILL IT IN AND RETURN IT TO  

mich@muchaadventure.com

at least

ONE WEEK BEFORE YOUR EVENT STARTS

Mucha Adventure ACTIVITY ___________________________________

Date ________________­­­­­______

­­­­­­

Terms and Conditions 

The following terms and conditions apply.

In no activity, including, but not limited to the above mentioned activity, shall this group or the groups organiser be liable for any damages whatsoever, whether direct, indirect, general, special, compensatory, consequential, and/or incidental, arising out of or relating to the conduct of you or anyone else in connection to Mucha Adventure, including, without limitation, bodily injury, emotional distress, and/or any other damages resulting from this or any other activity undertaken within the group.

You acknowledge that you are physically and mentally capable of undertaking the activity without any risk to your safety and the safety of others in the group.

Mucha Adventure reserves the right to withdraw services from customers that are impacting on the enjoyment or safety of other customers but not limited to the physical, medical or mental inability of customers to undertake the arrangements of the event/tour, unsocial or unruly behaviour, or the carriage of prohibited substances or materials.

  • Waiver Assumption of Risk and Complete Release of Liability

I UNDERSTAND THAT THE PURPOSE OF SIGNING THIS DOCUMENT IS TO EXEMPT AND RELEASE MUCHA ADVENTURE OR ITS ORGANISERS AND PARTICIPANTS HEREINAFTER AS REFERRED TO AS “RELEASED PARTIES” AND TO HOLD THESE ENTITIES HARMLESS FROM ANY AND ALL LIABILITIES ARISING AS A CONSEQUENCE OF THE FOLLOWING, OR ANY OTHER ACTS OR OMISSIONS ON THEIR PART, INCLUDING BUT NOT LIMITED TO ANY NEGLIGENCE OF ANY TYPE.

  1. I understand that I have a duty to exercise reasonable care for my own safety and the safety of others and I agree to do so.
  2. I assert that I am physically fit to undertake the above activities and I will not hold the released parties r​esponsible for any problems (medical, accidental or otherwise) which occur whilst undertaking these activities.
  3. I understand that I must not be under the influence of alcohol or non-prescription drugs when undertaking any activities organised and managed by Mucha Adventure.
  4. It is my intention by this instrument to give up my right to sue all persons or entities referred to herein, whether specifically named or not and it is also my intention to exempt and r​elease all released parties ​and to hold these entities harmless for any or all liability for personal injury, property damage or wrongful death. I assume all risk in connection with undertaking the above activity and the organisation of this activity.
  5. I have carefully read this contract in its entirety, fully understand its contents, and agree to the terms and conditions of this contract on behalf of myself. This document constitutes the final and entire agreement between r​eleased parties ​and the undersigned. There are n​o warranties e​xpressed or implied which extend beyond the description of the activity listed on this form. This is a complete release of liability and a legally binding contract.

I have read this agreement and I am aware that it is a release of liability and a contract between myself and the​ Released Parties, ​I sign it of my own free will and agree to be bound by it, from the date of my signature, forever into the future.

Signature of Participant_______________________________________________

Signature of Legal Guardian (if under 18)        

Date    ____/_____/____              Telephone Number (____)_____­__________________                                           

                                  

 

 Swimming Ability – Please circle the distance you can comfortably swim (any water activities)

 

          N/A      100m+     Up to 100m       Up to 50m       Up to 25m       Non Swimmer    

 

 

I agree to the use of my image for use by Mucha Adventure promotional purposes.    

 

YES/NO

 

 

I agree to being contacted by email by Mucha Adventure to be advised of upcoming events that may be of interest to me.  

 

YES/NO

 

 

Email address__________________________________________________________________________

 

 

Emergency Information

 

 

Emergency Contact Name___________________________________________________________

 

Phone Number ________________________________Relationship_________________________  

 

 

Please note any/all medical conditions and any other information that may be relevant to your undertaking these activities.  

 

Please also advise specifically on the following

 

ASTHMA______________________________________________________________________________

 

ALLERGIES (Food/Medication/Insects/Other)_______________________________________

DIABETES_____________________________________________________________________________

 

HEART CONDITION___________________________________________________________________

 

OTHER RELEVANT INFORMATION________________________________________________________________________

________________________________________________________________________________________

 

This information is relevant to ensure we can help look after you in case of an unexpected event occurring.

Signed and Dated ____________________________________________________________________

 

ANY DIETARY REQUIREMENTS______________________________________________________________________

 

______________________________________________________________________________________________