Medical Release Form

  • RELEASE, INDEMNIFICATION, AND WAIVER FORM
    THIS IS A LEGAL RELEASE -- PLEASE READ IT CAREFULLY

    I, the undersigned, hereby acknowledge that I have been advised and fully understand that certain elements of danger are inherent in the activities sponsored by Quiet Heart Wilderness School, which are beyond the control of the instructors, agents, officers, students and employees of Quiet Heart Wilderness School, and that participation in any program activities may entail unavoidable risk of personal injury, death, and loss of or damage to property. These risks include, but are not limited to, insect and animal bites and stings, forces of nature such as but not limited to lightning, and unexpected extreme weather conditions, any hazard present in the wilderness, such as but not limited to low lying branches, sticks, sharp objects, and slippery surfaces; negligence, careless acts or omissions by a Quiet Heart instructor, agent or employee.

    I hereby assume all risks of injury and death to myself (or my child) and loss of or damage to property arising out of my (or my child’s) participation in such activity and I agree to indemnify, hold harmless Quiet Heart Wilderness School, its instructors, agents, officers, and employees from and against all claims arising from any occurrence or negligence causing damage or injury to myself (or my child) or to any party participating in said event or any third party injured as a result of my (or my child’s) actions. I further agree to repair or reimburse Quiet Heart Wilderness School for any and all damages that I (or my child) cause Quiet Heart Wilderness School property or the property at which a specific activity is held.

    Provided parents or emergency contacts cannot be reached within reasonable time, I hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment, by authorized members of the hospital staff or their designees, as may in their professional judgment be necessary. I hereby acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on child’s condition. I acknowledge that I am responsible for all reasonable charges in connection with care and treatment rendered during this period.

    Any and all disputes are subject to Washington State law and are to be brought in Snohomish County.

    I have read the foregoing and understand the terms and conditions of this Release, Indemnification and Waiver and I agree to subscribe to them.

  • Student Profile

  • Medical Information Form

  • Please provide two Emergency Contacts Other than Parent(s):
  • If there are any personal medical conditions or problems a student may have, Quiet Heart Wilderness School should be made aware of any condition. It is the responsibility of the individual (or parent when a minor child is the student) to acquaint Quiet Heart Wilderness School with the existing condition. The information will be held in confidence and used only to render assistance should the need arise.
  • Is student allergic to any of the following (please identify):
  • HEALTH INSURANCE INFORMATION