Lost Creek Adventures - Assumption of Risk, Informed Consent and Release of Liability Form
Lost Creek Adventures LLC                          
715-953-2223
Mailing:  21740 Siskiwit Lake Road - Cornucopia, WI 54827       
Storefront: 22475 Hwy 13 - Cornucopia WI 54827 
Activity name that you are completing this waiver for *
Date of your ACTIVITY (Start date for multi-day activities) *
MM
/
DD
/
YYYY
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.) *
Your answer
I certify that I am at least 18 years old. *
Required
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. *
Required
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. *
Required
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.) *
Required
Emergency Medical Treatment Statement: *
Required
To the best of my ability, I will follow all LCA staff instructions, rules, policies and will act responsibly and safely towards other participants. *
Required
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. *
Required
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy