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Zion Mountaineering School

Liability & Medical Waiver

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medical Questionnaire. All fields are by default "no". If any of these conditions exists or are pertinent to today's activity please mark "yes" and explain in the box. This information is necessary for our guides to safely manage the day and not a determination of your ability to participate.
Vision/Hearing Impairment*
No
Yes

If yes, Please Explain
Broken Bones*
No
Yes

If yes, Please Explain
Hospitalization in past year*
No
Yes

If yes, Please Explain
Muscle Impairment*
No
Yes

If yes, Please Explain
Urinary Tract condition*
No
Yes

If yes, Please Explain
Intestinal Problem*
No
Yes

If yes, Please Explain
Arm or Hand Problem*
No
Yes

If yes, Please Explain
Leg or Knee Problem*
No
Yes

If yes, Please Explain
Foot or Ankle Problem*
No
Yes

If yes, Please Explain
Back or Spine Problem*
No
Yes
Severe Sprains*
No
Yes

If yes, Please Explain
Diagnosed Mental Illness*
No
Yes

If yes, Please Explain
Severe Anxiety & Depression*
No
Yes

If yes, Please Explain
High Blood Pressure*
No
Yes

If yes, Please Explain
Asthma*
No
Yes

If yes, Please Explain
Diabetes*
No
Yes

If yes, Please Explain
Seizures*
No
Yes

If yes, Please Explain
Chronic Headaches*
No
Yes

If yes, Please Explain
Shortness of Breath*
No
Yes

If yes, Please Explain
Women - Are you Pregnant?*
No
Yes
Chest Pain*
No
Yes

If yes, Please Explain
Please List any allergies or prescription medications you are taking

Explain
Canyoneering and or Rock Climbing Experience

Explain
How did you hear about Zion Mountaineering School
How did you find Zion Mountaineering School*
Internet search
Brochure
Word of mouth
Trip Advisor
Referrel
Return Client
PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK

In consideration of the services of Zion Mountaineering
School,  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 "ZMS"), I hereby
agree to release, indemnify, and discharge ZMS, on behalf of myself, my
children, my parents, my heirs, assigns, personal representative and estate as
follows:

1. I acknowledge that my participation in rock and/or
ice climbing, canyoneering, mountaineering, snowshoeing, backcountry skiing,
snowboarding, and/or hiking 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: the hazards of walking on
uneven terrain and slips and falls; being struck by rock fall, icefall or other
objects dislodged or thrown from above; the use of climbing ropes and
equipment; the forces of nature, including lightning, weather changes and
avalanche; the risks of falling off the rock, mountain or into a crevasse; the
risks of exposure to insect bites; the risk of altitude and cold including
hypothermia, frostbite, acute mountain sickness, cerebral and pulmonary edema;
my own physical condition, and the physical exertion associated with this
activity.

Furthermore, ZMS employees have difficult jobs to
perform. They seek safety, but they are not infallible. They might be unaware
of a participant's fitness or abilities. They might misjudge the weather, the
elements, or the terrain. They may give inadequate warnings or instructions,
and the equipment being used might malfunction.

2. 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.

3.  I hereby voluntarily release, forever discharge, and agree to indemnify and hold
harmless ZMS 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 ZMS 's
equipment or facilities, including any such claims which allege negligent
acts or omissions of ZMS.

4.  Should ZMS 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.

5.  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.

6.  In the event that I file a lawsuit against ZMS, I agree to do so solely in the state
of Utah, 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 if 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 ZMS 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.

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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