| First Name |
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| Last Name |
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| Address |
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| City |
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| State |
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| Zip Code |
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| Day Phone |
Example:559 222 1234 |
| Night Phone |
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| E-mail Address |
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| Gender |
Male Female |
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Race* |
White
Black
US Indian
Asian
Hispanic
Other
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| |
*Ethnic information is required in order to qualify for
government grants.
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| Age |
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Hiking and
Backpacking Experience |
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Have you ever hiked before? |
Yes No |
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If yes, your average hike is: |
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Can you do extended backpacking trips of
25 miles or more? |
Yes No |
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Special Dietary Requirements |
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Do you have any food allergies? |
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Do you have any dietary
restrictions? |
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Are you a Vegetarian?
Please provide
suggestions for alternative menu choices:
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Medical
Information |
| Emergency contact information; please submit 2
people: |
| Name#1 |
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| Address: |
|
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| Phone: |
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| Name#2 |
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| Address: |
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| Phone: |
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| Do you have any physical disabilities or prior injuries which
may affect your participation in this activity? Enter "none" of none. Please
explain: |
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| |
Are you currently taking any medication for an illness,
disability or other medical condition such as DIABETES or HIGH BLOOD
PRESSURE? Enter "none" if none. Please list ALL
medications:
(This
information is absolutely critical; different medications react
differently at higher altitudes. CONSULT YOUR DOCTOR about the side
effects of high altitudes!!) |
|
|
| Please list any known allergies to plants, insects or
medications such as PENICILLIN. |
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| When
was your last tetanus shot? |
|
Example: Jan 1998 |
|
The following polices have been established for pets that attend HSVTC events. These policies must be adhered to or you will be asked to leave the event.
- All dogs must have proof of current rabies vaccination
- All dogs must be on leash while in base camp, around the campfire
- No dogs will be allowed in kitchens, cooking areas and food serving locations
- Any dog that exhibits any anti-social behavior towards volunteers, forest service employees or other persons, the Owner will be immediately instructed to remove the pet from the location, and restrained until they are instructed that restraining is no longer needed
- The care and feeding of any pets is totally the responsibility of the Owner
- The possession or presence of weapons and firearms is strictly prohibited on our activities in the absence of special advance approval - written permission from Shane Krogen and a review and approval of the HSVTC, Board of Directors, US Forest Service, State of California, and local Sheriffs department approval. This approval process takes up to 6 months to complete.
Acknowledgement and Assumption of Risks and Hazards
In this Acknowledgement and Assumption of Risks and Hazards, the HSVTC will set forth some of
the risks and hazards that are present due to your participation in these activities. The list
below does not cover all potential risks or hazards but is intended to be illustrative of those
risks and hazards and to make sure you understand that the activities do entail risks and hazards
some of which may not be forseen by HSVTC. In reading and agreeing to this Acknowledgement and
Assumption of Risks and Hazards or by participating in the activities, you are voluntarily
assuming any and all risks attendant to your participation in these activities whether
specifically listed herein or not. If you are not willing to voluntarily assume these risks, we
regret that you may not participate in the activities.
1) The presence of weather conditions which may result in becoming wet or cold, injured or
exposed to the elements and hypothermia, heat or sun related injuries or illnesses including
sunburn, sunstroke, or dehydration, fatigue, chill and/or dizziness, which may diminish my/our
reaction time and increase the risk of an accident.
2) The presence of personal conditions or symptoms, such as impaired balance, diminished physical
coordination, reduced ability to properly operate equipment, and reduced ability to follow
instructions.
3) The risks associated with travel to project sites as well as travel within project sites and
areas. This travel may include Volunteer’s own vehicles as well as USFS vehicles.
4) The presence of wildlife such as mountain lions, bear, deer, snakes, insects and other life
forms, poisonous or toxic plants such as Poison Oak and Ivy. Contamination of water which may result in illnesses from giardia, bacteria, and other protozoan cysts.
5) Risk of delayed access to medical treatment due to considerations of distance, terrain, weather
conditions, or other factors foreseen or unforeseen.
Although I fully understand the above I also understand that while I participate in these events
that the participants will be considered federal employees for the purpose of tort claims and
compensation for work injuries.
Very Important! By typing yes in the box below I acknowledge
that I have read, understand and agree to voluntarily assume any and all risks of the activities
and specifically acknowledge that this may include assuming risks and hazards currently not forseen
by HSVTC. Further, in voluntarily assuming these risks and hazards, I agree to release and hold
harmless HSVTC, its Board of Directors, employees and officers, the United States Forest Service,
its employees and agents, and any other participating governmental agency and its employees and
agents from any claims or losses due to injury, illness, loss of work time or any other damages
that may result from the risks and hazards of the activities.
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I
understand and accept the foregoing:
(Please type:
yes in lower case) |
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