Challenge Mountain Snowsports Day Registration

Please print, fill out in entirety and bring to ski appointment for Challenge Mountain Adaptive Recreational Facility.  If you are scheduled to for your appointment at Boyne Mountain, please go to

Challenge Mountain/Boyne Mountain Outreach Registration

Challenge Mountain of Walloon Hills, Inc.

2205 Springbrook Rd. Boyne Falls, MI 49713

(231)535-2141, Lodge

Permission for Emergency Care                  Date____________________________

Volunteer / Client (circle one) Name__________________________________________

Address_________________________________________________________________

City______________________________State___________Zip____________________

DOB________________________Age____________Height_________ Weight_______

Shoe Size____________________

Parent/Guardian Name_____________________________________________________

Address if different than above______________________________________________

Phone______________________________Alternate Phone_______________________

Emergency Contact Person_____________________________ Relationship__________

Medical Insurance Information/ID#___________________________________________

Known Allergies__________________________________________________________

Current Medications_______________________________________________________

Any reactions to prescribed medication, (ex: sun sensitive, drowsiness, cannot eat certain foods___________________________________________________________________

Name of Physician_____________________________Phone______________________

I _________________________________hereby give my permission for emergency care to be sought and/or given to myself or above named individual in the event that I cannot be contacted or am incapacitated.

Release of Liability/Consent

I am aware that injury or event death may occur to participants in this event.  Some of the dangers involved in this activity include terrain changes, tree location, hill machinery and/or possible physical exertion.  There are inherent risks involved with any Challenge Mountain activities.

____________________ Initial you have read and understand.

This event involves physical activity and exertion.  I submit that the participant is in sound physical condition with no health problems that could be aggravated by participation in this event.  I release and discharge Challenge Mountain and their agents from all claims for damages arising directly or indirectly from applicant’s participation in such activity. ___________________________ Initial

I may or may not have inspected the equipment, site, and facilities.  Nevertheless, I assume all risk associated with this event, participation in it, including but not limited to the conditions of the equipment, site(s), facilities, and the unknown ability of other participants.  ___________________Initial

(Over)

I give permission for the participants photograph to be used for media relations, fundraising, and identification of client for medical purposes. ________________Initial

Furthermore, Challenge Mountain maintains volunteers of staff that have received citizen level CPR and first aid training.  There volunteers act solely on their own accord and Challenge Mountain will not be held liable for their actions.  The acts of volunteers are covered under the theory of Good Samaritan, which releases them from liability.  Challenge Mountain will maintain infection control, first aid, and barrier protection.

It is my express intent, by signing this release and participating in this event, to waive, relinquish, and release any claims, which I might have against any and all volunteers, directors, executive directors, officers, agents, and employees of both Challenge Mountain of Walloon Hills, Inc. and also the organizations called Challenge Mountain of Walloon Hills, Inc.  I intend this release of liability to be effective against me, my spouse, my heirs, successors, and assignees.

By signing the Release of Liability, I signify that I have read and understand it.  I also understand that my participation is dependent upon my knowing and voluntary execution of this Release of Liability.

Print Name______________________________________

Signature__________________________________________________

Date___________________________________

For Challenge Mountain Use Only

Age____________                                                                Ski Boot Size___________

Height__________                                                                 Boot Sole Length________

Weight__________                                                                Ski Length_____________

DIN_______________                                                         Snowboard Boot #_______

Tech Int.___________                                                           Board #_______________

Ski number__________________

Physical or emotional challenge____________________________________________________

Type of adaptive equipment and number_______________________________________

______________________________Revised 11/17/2004