Ea acknowlegement of risk.doc

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ACKNOWLEDGMENT OF RISK
- CONDITIONS FOR ADULTS -
Warning – This is an important document which affects your legal rights and obligations, please read
it carefully. If you have any questions please call the office on 8165 2022.
I, ___________________ acknowledge that Earth Adventure will provide me with access to a variety of
activities which will be supervised by Earth Adventure (“the activities” as per the one booked into).

I acknowledge that these activities may have inherent danger or risk involved and I acknowledge
responsibility for my involvement in these activities.
I acknowledge that during all such times whilst participating in the activities both my property and my person
shall be at my own risk and I will not hold Earth Adventure liable for any personal injury or loss of property
whatsoever and I agree to indemnify and keep indemnified Earth Adventure against all such injury or loss.
I agree that I will pay any repair or replacement costs for equipment that may be damaged by me.
I hereby authorise Earth Adventure, staff and consultants to obtain any necessary medical assistance for me
should any medical problem or accident occur and I expressly agree to be responsible for all such medical
expenses incurred.
I ___________________ give permission for Earth Adventure staff or consultants to administer to me
medication as instructed if I am not able to self administer this medication. I acknowledge that I will provide
all such medication to Earth Adventure in clearly labelled doses or original containers. Method of
administration provided by Earth Adventure instructors is limited to oral and topical.
I ___________________ give permission for Earth Adventure staff or consultants to use any photos or video
footage of myself taken while participating in the activities for use in brochures or other promotional material.
I ___________________ give permission in the case of an emergency, to be transported to hospital by
Ambulance and I expressly agree to be responsible for all costs associated with such transport and hospital
admission.
I ___________________ give permission for Earth Adventure staff or consultants to provide me with
VENTOLIN, if required in an emergency by a trained Asthma first aid person.
Where I am participating in a reoccurring activity such as the Pathfinder walking program conducted by Earth
Adventure I acknowledge that this document will apply to my participation in all of these events. Earth
Adventure may store this document as record of this acknowledgement.
Signed:. Name: . Date: ___/___/___
Witness: . Name: . Date: ___/___/___
Please send me information about the Earth Adventure programs yes / no (PEOPLE WILL BE SENT INFORMATION AS A DEFAULT RESPONSE IF A RESPONSE IS NOT INDICATED) All personal information will be filed in accordance with the Privacy Act, 1988.

Source: http://www.earthadventure.com.au/Files/EA%20acknowlegement%20of%20risk%2009.pdf