Participant
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Sex
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Ethnicity
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Parent/Guardian Name
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Cell Phone
(###)
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Email Address
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Parent/Guardian Employer
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Waiver
The activities of The Wilderness Experience, Leadership and Service Program (i.e. WELS) may involve strenuous physical exercise, exposure to changing weather and terrain elements, and the use of potentially dangerous equipment. They also demand the total attention and responsibility of each participant, either as an individual or part of a cooperating group. In addition, these activities include the inherent risk of fatigue, mental stress, injury or death. Your permission, indicated below, acknowledges these risks.
1. I understand that outdoor recreational activities and sports such as snowboarding, skiing, rock climbing, hiking, biking, rafting and teambuilding are HAZARDOUS ACTIVITIES. I understand that participation in such activities and the use of associated equipment involves risk of injury to any and all parts of my body. I understand that having a WELS staff member, representative or volunteer present does not lessen the amount or severity of the risks of these activities. I understand that WELS is not responsible for my safety. It is further understood that training or competing is more hazardous than recreational participation. Furthermore, I understand that I must keep deliberate and conscious control of my physical body, while properly using my equipment in variable terrain and weather conditions. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
2. I hereby certify that I am physically fit and have no medical conditions or allergies that affect my ability to participate in these activities.
3. I hereby freely and expressly assume and accept the responsibility for any and all risks of injury or death while participating in these activities or related activities, and I agree to RELEASE, FOREVER DISCHARGE, INDEMNIFY, DEFEND and HOLD HARMLESS The WELS Program, its directors, officers, agents, employees, sponsors, and volunteers, the United States Forest Service, the equipment manufacturers and distributors, all event sponsors and all of the resorts or entities that provide facilities for the conduct of these activities (hereinafter “releasees”) from any and all losses, damages, costs and attorney’s fees resulting from any and all claims or suits for personal injury, death and/or property damage that may in any way arise out of my participation in these activities, related activities, or my use of the releasees’ premises or equipment, regardless of how or by whom or by what the personal injury, death and/or property damage was caused. As a condition of my, or my child, being entitled to participate in such WELS activities, I hereby promise not to bring (on my behalf, on behalf of my child or otherwise) any claim against or sue RELEASEES in connection with such activities.
4. I voluntarily agree to release, forever discharge, indemnify, defend, and hold harmless the releasees from any and all claims, suits, costs and attorney’s fees for damage and personal injury to me, my child or my property resulting from the negligent acts or omissions of the releasees. I understand that the releasees are not responsible for the consequence of their own negligence, that is, their failure to use reasonable care in any way.
5. I understand that this agreement shall be binding upon my heirs, executors, administrators, and assigns and shall be governed by the applicable laws of the State of Pennsylvania. I also understand that if any part of this agreement is determined to be unenforceable, all other parts shall be given full force and effect.
6. I consent to the use by releasees of any pictures (video and print) for commercial purposes, or otherwise, of me in connection with the activities of WELS.
7. I agree that in the event of a medical emergency, The WELS Program, its agents, employees and volunteers, may provide emergency medical assistance deemed necessary under the circumstances. I further agree and authorize The WELS Program, its agents, employees and volunteers, to make any and all necessary arrangements for emergency care and I agree that these parties shall be free from any liability to me or my heirs for personal injury or loss resulting from my transportation to a medical facility.
8. I understand that permission to participate in The WELS Program and to use its equipment is being given to the undersigned participant in exchange for the execution of this Liability Agreement and Risk Release. I have read the above paragraphs and fully understand them. I understand that this is a RELEASE OF LIABILITY which will legally prevent me or any other person from filing suit or making any other claims for damages in the event of personal injury, death or property damage. I freely and voluntarily enter into this agreement. I have made no misrepresentations to releasees regarding my name, age, or medical condition.
Signature (Participant)
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First Name
Last Name
Signature (Guardian)
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First Name
Last Name
School
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Grade Level
Height
Weight
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Shoe Size
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Insurance Company Name
Insurance Policy Number
Insurance Group Number
Name on Insurance Policy
Child is Living with
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(Check all that apply)
Annual Family Income
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Questionnaire
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For each statement below, please indicate how much you disagree or agree with each statement. There are no right or wrong answers.
I know a lot of safe places to hang out.
A lot of adults think that I am an interesting person
I am able to get along with friends
I must stay out of trouble
I respect authority figures
I am creative
I can succeed in life
I try to treat other youth with respect
I try to solve problems in a positive manner
I have a desire to start/keep participating in outdoor recreation
I know a lot of activities in my community
I can turn to adults for help
There are other youth who like spending time with me
I must obey rules
I respect adults
I can set goals
It is important for me to always do my best
Teamwork is important
I try to control my anger
I want to improve my outdoor recreation
I am interested in participating in programs in my community
There are adults who will look out for me
I am a good person
I will be punished if I break the rules
I respect people in charge
I can deal with problems that might come up in the future
It is important for me to do well at school
Cooperation is important
I try to listen to the opinions of others
I am interested in outdoor recreation
I am interested in programs that take place after school
Adults are willing to help me with my problems
People I know want to spend time with me
I must follow the rules if I want to participate
I respect youth who stay out of trouble
I like to try new things
It is important for me to stay in school
When playing a game with my friends, all players need a chance
I can settle arguments without getting angry
I like outdoor recreation
Name
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Phone
(###)
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Cell Phone
(###)
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Relationship to Child
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Same Address as Participant
Address/City/State
Youth is permitted to
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People Allowed to Pick Up Youth
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Have you had recent injuries or surgeries? If yes, please explain.
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Does the participant have any allergies, special medical conditions or other special circumstances (including emotional or behavioral issues) that we should be aware of? If so, please explain
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Does the participant take any prescription medication? If so, please list medication name, dosage, and reason for prescription
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I hereby authorize WELS to transport my child for the purpose of getting him/ her to and from program activities
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I understand and agree that WELS may subsequently use for publicity and/ or promotional purposes pictures/ of youth participating in the activities without obligation or liability to the child
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WELS Program Participant Code of Conduct
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This form is to help WELS staff identify each youth's individual needs, and give an understanding of why you think your youth is eligible to participate in The WELS Program. All of this information is kept confidential and for office use only. The WELS Program aims to inspire underserved youth to build character, develop leadership skills, and make positive decisions for a healthy and successful life.
Please check ALL that apply. You must check AT LEAST TWO to be eligible to participate in The WELS Program - Applications with no listed options will be considered incomplete.
Other Reasons Not Listed Above or Additional Comments
