Upaya Zen Center JOURNEY TO MONGOLIA: BUNKHAN CAMP ...

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RELEASE AND ASSUMPTION OF RISK FORM Please return to: Upaya Zen Center 1404 Cerro Gordo Road Santa Fe, New Mexico 87501 Tel: 505-986-8518, Fax: 505-986-8528 UPAYA ZEN CENTER RISK AND LIABILITY Upaya Zen Center and its staff and representatives hereby give notice that they are acting as agents for hotels, transportation operators, tour guides and suppliers, and will not be held liable for any change or alteration of schedule due to natural causes, airline delays and changes, political unrest, illness, or other factors which are beyond their control. They are able to assume no responsibility for with the condition, operation or safety of any aircraft, vehicle, or accommodation, which may be made available to participants in an Upaya trek. Upaya Zen Center reserves the right to accept or reject any person as a trip member at any time. In the case of any inconvenience, injury, loss, or damage to clients, any extra cost in the abovementioned situations should be borne by the clients. Upaya Zen Center reserves the right to change, cancel or re-price any portion of this trip when deemed necessary. In the unlikely event of a trip cancellation, Upaya Zen Center will reimburse clients all monies due based upon the difference between the quoted trip price and the cost of services already provided. Participants on this trek assume the responsibility to be in good health and physical condition before the departure date, and are responsible for studying all pre-departure information as well as obtaining all of the necessary provisions as described in the trip information packet. I acknowledge and understand the risks of travel in remote areas where injury, delay, or unpredictable events may occur. I am aware that trip activities necessarily involve certain dangers and risks, including but not limited to: forces of nature; injuries that may be associated with exposure to the elements; injuries that may be associated with hiking, backpacking, climbing and swimming; injuries that may be associated with traveling to and from the pilgrimage/wilderness site; disease associated with international travel. With this awareness, affirming that my participation in any activity either at Upaya or in the field is my own choice, and in partial payment for the right to participate in this program, I do hereby assume full responsibility for such dangers and risks, and I do expressly release and will hold harmless Upaya and its agents and associates from any and all liability, actions, causes of action, debts, claims, or demands of every kind and nature whatsoever, which I now have or which may arise from or in connection with this program/pilgrimage or participation in other such activities. I agree to indemnify and hold harmless Upaya for all special expenses incurred by it in connection with any injury or danger suffered by me. The terms hereof shall constitute a release and assumption of risk by me and by all members of my family, including minors accompanying me, and shall be binding on my heirs, executors, and administrators, and on those of my family. I agree that if any portion of this release of risk/liability form is found to be void, the remaining portions of this agreement will remain valid. Signature:_________________________________ Date (mo/da/yr): _________________________ Name (printed):_____________________________ 12.04.09
Please fill out and return this form to Wild Earth Journeys/Thomas L. Kelly. www.WildearthJourneys.com TRAVELER PROFILE / MEDICAL PROFILE During you trip, you will be exposed to circumstances and living conditions that are likely to differ from those at home. Our programs involve a variety of activities that may include physical activities. The level of participation in a program activity is at all times completely up to the individual. It is possible that you may suffer an emotional or physical injury and /or disability. There is a risk, which must be assumed by each participant. By giving WEJ/Thomas L. Kelly a deposit for a trip and signing below, you are certifying that you do not have any physical or other condition, which would create a hazard for yourself or other travelers. It is essential that WEJ be informed in writing below of any medical condition you might have which requires regular treatment or which may be affected by vigorous activity, high altitude, heat, cold or other natural phenomenon or particular foods. This information is kept confidential and is available only to trip leadership/Thomas L. Kelly. If your trip requires a doctor's statement of adequate health an additional form will be mailed to you. 1.) Do you have any limitations to participating in normal group activities (i.e., walking, climbing steps)? Yes No (If yes, identify and explain:) 2.) Do you have any allergies or reactions to medication? Yes No (If yes, identify and explain:) 3.) List prescribed medications you are currently taking and for what conditions? 4.) Are you currently under the care of a medical professional? Yes No (If yes, a medical release must be provided by your doctor.) 5.) Do you have any restrictions or food preferences in your diet? Yes No (If yes, give details:) 6.) Is there any other medical conditions which might affect your ability to participate in this trip? 7.) Do you smoke? Yes No 8.) Do you snore? Yes No I don’t know Person who will be available to contact in case of emergency: Name:____________________________ Phone: ____________________________ Relationship:______________________ Fax:_____________________________ 12.04.09
Page 1 and 2: Upaya Zen Center JOURNEY TO MONGOLI
Page 3 and 4: Trip cost: US $4500; Deposit $500.0
Page 5: Health Insurance: _________________
Page 9 and 10: TRAVEL ARRANGEMENTS: Early bookings
Page 11 and 12: MEDICAL CHECKLIST Aspirin or parace
Page 13 and 14: BASIC RULES: FOOD There is an old s

Upaya Zen Center JOURNEY TO MONGOLIA: BUNKHAN CAMP ...

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