Ecoventure of rangeley

Rangeley Lakes Heritage Trust
The following information is needed by your guide to ensure safety and act quickly in case of an emergency. All information will be kept confidential between you and your guide.
Participants Name:______________________________________________________ Address: _______________________________Town/State/Zip: _____________________ Phone: _______________ Eye Color:_______________ Hair Color: ________________ Confidential Medical/Health Information
The Rangeley Lakes Heritage Trust will keep all medical information confidential and can accommodate a variety of mild medical
conditions; we urge you to be frank and honest for your own safety and the safety of others on the outing.
Are you under medical treatment that requires medical treatment on the trip? If so explain:
Have You Had A Recent Problem With:
Recent operations or serious injury: _________________ ____________________________________________ ____________________________________________ Current medications: ____________________________ ___ Lung Problems ___ Heat Stroke ___ Heat Exhaustion ____________________________________________ ____________________________________________ ______________________________________________________ Please describe the above and if medications are required to control the above illnesses: Do you require prescription corrective lenses? Yes No _________________________________________ Note: A spare set of your medications and eyewear are to be kept on
_________________________________________ your Guide at all times. Most important are medications that control
or limit sudden onset distress such as asthma, chest pain, etc
_________________________________________ Family Physician:______________________________ Allergies:
Telephone: ( ___ ) ____________________________ Swimming Ability
___ Intermediate ___ Strong/confident Swimmer Canoeing Ability
___ Never ever ___ Beginner ___ Adv. Beginner ___ Intermediate ___ Strong/confident skills If you have checked anything above please explain Flyfishing Ability
___ Never Ever ___ Beginner ___ Adv. Beginner
reactiion severity, etc:_________________________ __________________________________________ Other ___________________________________________
Special Medical Permission: We have Benadryl (Diphenhydramine HCI) on hand in case of severe reaction to insect bite or
other reactions. Special permission is needed for us to administer Benadryl (Diphenhydramine HCI). I hereby authorize my Guide
_________________________ to assist me in the administration of Benadryl (Diphenhydramine HCI) in the event of a severe
reaction to insect bites/stings or other allergen.
Emergency Numbers: Please provide four (2) separate numbers on how we can contact your family member or family friend in
the event of an emergency. Please make sure at least one of these numbers is outside of your home contacts.
1. Name: ___________________________ Phone: ________________________ Address: _________________ 2. Name: ___________________________ Phone: ________________________ Address: _________________ Please return this sheet, signed, with your paperwork.
Rangeley Lakes Heritage Trust
Acknowledgement of Participation and Acceptance of Risks and Liability Release
(READ THIS DOCUMENT CAREFULLY AND SIGN AT BOTTOM. CIRCLE “MYSELF” or “MY MINOR” WHERE HIGHLIGHTED)
For participation in a trip from (dates) to
All forms of activities such as, but not limited to, fishing, hiking, swimming, canoeing, kayaking, wildlife viewing, walking and traveling to and from activities have inherent risks and can be hazardous.
Rangeley Lakes Heritage Trust guides have been trained in First Aid, CPR, and dealing with
emergency situations and will strive to safeguard you / my minor at all times.
I am fully aware of these risks, and realize that injuries are a possibility no matter how attentive my Guide may
be. I accept full responsibility for any such damage or injury of any kind to myself / my minor or others that I
/ my minor may encounter, receive or perform during my trip with Rangeley Lakes Heritage Trust. As a
condition of being permitted to participate in an engagement with Rangeley Lakes Heritage Trust, I agree to
release, hold harmless, and indemnify my guide, ______________, it’s agents, partners, or land owners
participating in this program/trip. I freely accept all risks of injury, death, or property damage occurring
thereon as a result of participating in any activity with Rangeley Lakes Heritage Trust.
I further agree that any claim that I may at any time bring, for any reason, against any of the above named, shall be submitted to the jurisdiction of the State or Federal Court in the State of Maine and no other jurisdiction, and shall be governed by the laws of that state.
As an adult of legal age, I acknowledge that I am authorized to sign this Agreement as representation for myself, named below. If applicable, as an adult of legal age, I acknowledge that I am authorized to sign this Agreement as representation for minor child, _______________________. I agree to be bound by the Acknowledgement and Acceptance of Risks and Liability Release and hereby indemnify the above named parties for awards, legal expenses, and settlements arising out of my participation in the activities of the Rangeley Lakes Heritage Trust In the event of an emergency, my Guide, ____________________ will do all in her/his power to contact my /
my minor’s emergency contact persons shall I not be able to do so. In the event that one of my emergency
contacts can’t contact immediately, my signing below authorizes my Guide, ___________________, to
procure emergency medical attention for myself / my minor and obtain further medical evaluation if so
determined.
Participant’s name (printed): ________________________________________ Date: _______________
Participants signature: _____________________________________________ Date: _______________
Parent/Guardian name printed (if applicable): __________________________ Date: _______________
Parent/Guardian signature: __________________________________________ Date: _______________
Please return this sheet, signed, with your paperwork.
Please return this sheet, signed, with your paperwork.

Source: http://www.rlht.org/OAS-Medical-Liability-Release-1.pdf