Avenbury Lakes Tour Waiver & Emergency Information

THIS VERIFIES THAT I HAVE READ AND UNDERSTAND THE GROUP TOUR GUIDELINES OF AVENBURY LAKES AND WILL ABIDE BY THESE GUIDELINES WHEN PARTICIPATING IN ANY TRIP SPONSORED BY AVENBURY LAKES.  

BY SIGNING THIS WAIVER I RELEASE AND HOLD HARMLESS THE BOARD OF DIRECTORS OF AVENBURY LAKES, ITS AGENTS AND /OR REPRESENTATIVES, FROM ANY LIABILITY FOR ANY INJURY, ACCIDENT, THEFT, LOSS OR DAMAGE TO PROPERTY WHICH MAY OCCUR ON ANY TRIP SPONSORED BY AVENBURY LAKES.

SIGNATURE__________________________________________________


DATE______________________  


PLEASE PRINT THE INFORMATION REQUESTED BELOW. ONE COMPLETED WAIVER PER PERSON PER YEAR IS REQUIRED TO ASSURE A SAFE AND CARE-FREE TRAVEL PROGRAM. THANK YOU FOR YOUR COOPERATION! 

NAME ________________________________________________________________


ADDRESS ____________________________________________________________________________________


Cell Phone Number ___________________________ Home Phone Number________________________________


EMERGENCY CONTACT ________________________________________________________________________
  Name/Relationship

  Phone Address City/State/ Zip ____________________________________________________________________


EXISTING HEALTH CONDITIONS____________________________________________


ALLERGIES______________________________________________________________


MEDICATIONS (RX) TAKEN_________________________________________________


IS THERE ANYTHING YOU FEEL WE SHOULD KNOW ABOUT YOUR CURRENT HEALTH STATUS? 

______________________________________________________________________________________________

______________________________________________________________________________________________

SPECIAL REQUESTS____________________________________________________________________________

______________________________________________________________________________________________


rn:05/01/13