Lost Creek Adventures - Assumption of Risk, Informed Consent and Release of Liability Form
Lost Creek Adventures LLC
Mailing: 21740 Siskiwit Lake Road - Cornucopia, WI 54827
Storefront: 22475 Hwy 13 - Cornucopia WI 54827
Activity name that you are completing this waiver for
Sea Caves 1/2 Day - kayaking
Sea Caves FULL Day - kayaking
Sand Island In A Day - kayaking
Romans Point - kayaking
Introductory Safety Course
Sand Island Overnight (2 day kayak camping)
Oak Island Overnight (2 day kayak camping)
Island Wanderer (3 day kayak camping)
Apostle Islands Exploration (4 day kayak camping)
Performance Paddler (4 day kayak training and camping)
Wilderness Explorer (5 day kayak camping)
Outer Limits (6 day kayak camping)
Date of your ACTIVITY (Start date for multi-day activities)
Your LAST name then FIRST name. Then the names of any children under 18 years of age that you are signing for. (Please separate names with a comma.)
I certify that I am at least 18 years old.
I certify that I am at least 18 years old.
I, the undersigned participant, and in the event the undersigned is younger than eighteen (18) years of age, the undersigned’s parent and/or guardian, am aware that certain elements of this tour/class/etc. (hereafter termed “activity”) can be physically and emotionally demanding.
I understand and voluntarily choose to participate. If signing for another person I agree to inform them of the details of this activity.
Lost Creek Adventures LLC follows reasonable and prudent safety procedures, however risks cannot be completely eliminated. I understand and assume certain risks (such as those listed below) due to weather conditions, changing water conditions, natural and human hazards, incidents related to travel to, from, or during the activity, and/or physical infirmaries. Following is a representative listing of the potential hazards to participants that are inherent to the activities one may be involved in while participating in a Lost Creek Adventures activity. This is not meant to be a complete listing as other injuries are certainly possible; Fatigue, chills, dizziness, lacerations, punctures, cuts, contusions, fractures, internal and soft tissue injuries, injection of venom, introduction of disease producing organisms by virtue of being attacked and/or bitten by animals, falling or encounters with trauma-producing objects found on site or around vehicles or at other sites being used for the activity, infection, serious injuries to head, neck or spinal cord, all bones, joints, ligaments, tendons, and other aspects of the musculo-skeletal system, serious injury or death resulting from lightening strike, falling trees, heat-related or cold water immersion, drowning or inhalation of water, and serious injury, paralysis, or impairment of other aspects of the participants body, general health, and emotional well-being.
I understand that there are risks inherent to the activity that I will be engaging in, and have informed myself and those in my care of those risks.
Due to forementioned risks, Lost Creek Adventures LLC and its staff/employees need to be aware of any pre-existing physical or emotional limitations that I or those in my care may have. (You will have the opportunity to describe your pre-existing concerns on this form after signing.)
By checking this box I am stating that I will notify the leaders/instructors of any physical or emotional limitations in person or on this form, or have none to report.
Emergency Medical Treatment Statement:
I hereby give permission to LCA activity leaders to render first aid and obtain emergency medical treatment as they see fit, and at my own cost.
To the best of my ability, I will follow all LCA staff instructions, rules, policies and will act responsibly and safely towards other participants.
I acknowledge that a staff member of Lost Creek Adventures LLC has the right to modify the activities or my participation in the activities to maintain the safety of the participants and the environment.
I agree that my activity may be modified in order to increase safety and comfort of myself and the other participants.
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