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Page 1 : Medical Information

Identity












Medical History











Personal Information


Medical Insurance Information






Emergency Contact  
Please provide the details of an emergency contact below:






Additional Information

Page 2: Dietary Restrictions 

Food Restrictions


Food Allergies




For every additional food allergy you have please select "add another response" to share specific details about each allergy.
We are asking that you reach out to us directly if your food restrictions or allergies change in the time leading up to this school.  In submitting this form, you are agreeing to this expectation.  You can reach us at 18inchjourney@gmail.com.  Thank you!

Page 3: Liability Information

I have willingly agreed to participate in the 18 Inch Journey Phase One school.  By signing my name I am stating that I have read and agree to all of the following:

1.  Responsibility for Risk and Loss.  To the best of my knowledge, I am in good physical condition and fully able to participate in the 18 Inch Journey.  I am fully aware of the risks and hazards connected with the participation of this event, including physical injury or even death, and hereby elect to voluntarily participate in said event, knowing the associated physical activity may be hazardous to me and to my property.  I voluntarily assume full responsibility for any risks or loss, property damage, or personal injury including death, that may be sustained by me, or loss, or damage to property owned by me, as a result of participation in this course.  

I hereby covenant not to sue, and release, waive, and discharge A Place for the Heart, the 18 Inch Journey, and their staff and volunteers from any and all liability, claims, demands, action and causes of actions whatsoever arising of or related to any loss, damage or injury, including death, that may be sustained by me or to any property belonging to me while participating in physical activity, or while on or upon the premises where the event is being conducted.  

It is my expressed intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to sue the above-named releasees.  I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of North Carolina. 

2.   Risks of Sports, Recreation and other Activities. In consideration of the use of exercise equipment, the lake, and other sports and recreation facilities and/or participation in any activity conducted by the 18 Inch Journey,  I accept and assume full responsibility for any and all injuries, damages (both economic and non-economic), and losses of any type, which may occur to me and or any other person in connection with any of the foregoing.  I hereby fully and forever release and discharge the 18 Inch Journey and its current and former staff, volunteers and representatives from and against any and all present or future claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated, or unanticipated, resulting from or arising out of the use of said equipment and facilities, including with respect to any personal injuries or damage to property sustained by myself or any other person. 

I understand that the 18 Inch Journey and A Place for the Heart does not provide supervision, instruction or assistance with respect to the use of facilities and equipment unless expressly and specifically stated otherwise.  For those activities that have supervision and instruction, I agree that in consideration of participating in the training and instruction provided, I understand and agree that the 18 Inch Journey staff and volunteers shall not be liable for any claims or damages arising from any injury as a result of my participation in the instruction provided.  I understand, acknowledge, and assume any and all risks in connection with the use of any and all equipment and facilities, including, but not limited to risk of serious injury, permanent disability and death.  

3.   Photo and Video Release. I hereby grant the 18 Inch Journey the irrevocable right and permission to use photographs and/or video recordings of me on the 18 Inch Journey, Cageless Birds and A Place for the Heart websites and other websites and on social media platforms and in publications and promotional flyers or for any similar purpose without compensation to me.  I understand and agree that such photographs and videos of me may be placed on the internet.  I also understand and agree that I may be identified by name and/or title in printed, internet, or broadcast information that might accompany the photographs and/or videos of me.  I waive the right to approve the final product.  I agree that all such portraits, pictures and photographs, video and audio recordings, and any reproductions thereof, and all negatives, recording files and digital files are and shall remain the property of the 18 Inch Journey.  I hereby release, acquit and forever discharge the 18 Inch Journey and its staff and volunteers, from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use of or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.  

In signing this release, I acknowledge and represent that I have read the forgoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed.  No oral representations, statements or inducements, apart from the foregoing written agreements, have been made.  I am at least eighteen (18) years of age and fully competent; and I execute this release for full, adequate and complete consideration fully intending to be bound by same. 

I acknowledge that typing my name below represents my e-signature and my complete agreement to the contents of this form.