REGISTRATION FORM

We do our best to ensure that everyone on a Candlebox Kayaking trip stays comfortable, healthy, and safe. Enjoying the outdoors in remote places does involve risk. Emergency treatment can be limited and transportation to a hospital can be dangerous, lengthy, and can require dozens of people and departments. Therefore, it is important that we know as much as possible about the health of every one of our guests to ensure the overall safety of the group. This information will be kept confidential unless emergency medical treatment becomes necessary, in which case it will be used to carry out the appropriate response. Please take the time to thoroughly complete this form. It is for your safety.

Please Complete

First Name

Last Name

Address

Home Phone

Mobile Phone

Birthday

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Home Phone

Emergency Contact Mobile

Doctor's Name

Doctor's Phone

If you answered yes to any of the above, please elaborate

By checking the line to the right, I agree that I have honestly answered the above questions and have disclosed the information requested. I understand that by withholding any of this information, I am putting others and myself at risk. If there are any changes to my state of health during this trip that affect my ability to participate safely, I will notify Candlebox Kayaking staff immediately.

By checking the line to the right I acknowledge that I am under 19 years of age and my parent or guardian agrees to the above statement on my behalf.

Name of Registrant

Applicant Signature

Select a date

Parent or Guardian Name (if under 19)

Parent or Guardian Signature

Select a date

Thanks for completing the registration.

REGISTRATION FORM

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