Participant Disclaimer Form

Activity & Site _______________________________

PART 1 : General information (Please Print)
1.

First Name : ______________________Last Name:___________________________________

2.

Street :_________________________Town:__________________Country:_______________

4.

Home Phone: _____________ Cell Phone:_____________5. Birth date : ____/____/____

6.

Height : _____cm

7. Weight ______Kg 8. Foot size ____ 9. Male [

] Female [

Po Box 289 – Curepipe
Rep. of Mauritius
Tel (230) 254 6607
Fax (230) 395 3207
Vertical@verticalworldltd.com
Verticalworldltd.com

]

10. National ID/ Passport #:______________________ Email: ______________________________
11. Person to be notified in case of emergency:
Name :___________________________________________________________________________________________
Full Address : ___________________________Phone : ________________Relationship________________________

Part 2 : Photo/Media Release (optional)
I grant to VERTICAL WORLD LTD. The rights to use, reproduce, assign, and/or distribute photographs, films, videotapes, and
sound recordings of myself, for use in promotional materials they may create. I understand that good faith efforts will be made
to contact me and to obtain final approval of any materials proposed for such.
Signature: ____________________

Part 3: Medical coverage & History
This information will be read by your VERTICAL WORLD LTD. facilitator ONLY and kept in strict confidence. You may
ensure confidentiality by returning this form prior to program in a sealed envelope with your name on the outside.
Please tick if you have problems with any of the following :
1. Problem with hearing – hearing aid
[ ] Yes [ ] No
2. Shortness of breath, asthma on exertion
[ ] Yes [ ] No
3. Chest pain on exertion
[ ] Yes [ ] No
4. Palpitation of the heart, irregular heartbeat, heart murmurs
[ ] Yes [ ] No
5. Low or high blood pressure
[ ] Yes [ ] No
6. Heart attack
[ ] Yes [ ] No
7. Hernia
[ ] Yes [ ] No
8. Chronic pain in neck, back, shoulders arms or leg
[ ] Yes [ ] No
10. Broken bones, joint dislocations, serious sprains, and weakness of muscles
[ ] Yes [ ] No
11. Joint pains, stiffness or swelling without injury.
[ ] Yes [ ] No
12. Any severe injury to head chest, internal organs
[ ] Yes [ ] No
13. Any surgeries in the past 5 years
[ ] Yes [ ] No
14. Severe illness requiring hospitalisation or prolonged incapacitation
[ ] Yes [ ] No
15. Episodes of depression, anxiety, hysteria, nervousness
[ ] Yes [ ] No
16. History of diabetes, thyroid trouble, bleeding problems
[ ] Yes [ ] No
17. Currently on any medication : __________________
[ ] Yes [ ] No
18. Special dietary restrictions
[ ] Yes [ ] No
19. Hypoglycaemia
[ ] Yes [ ] No
20. History of heat stoke or heat related problem, epilepsy.
[ ] Yes [ ] No
21. Any allergies ? ___________________________________________________ Reaction : ___________________
22. Swimming capacity : __________________________
If you have marked any of the above, please list details below according to item number. Please be specific!( e.g. include item
#, dates, names, history of conditions etc.)
___________________________________________________________________________________________________
I hereby declare that I have correctly filled this form to the best of my knowledge. I am aware that VERTICAL WORLD LTD. will
not be held responsible for injuries due to non-disclosure of medical information.
Signature : _______________________

Date (dd/mm/yy)

_______________________

Part 4: ACKNOWLEDGMENT AND ASSUMPTION OF RISKS
In consideration of the services of Vertical World Ltd, its agents,
employees, trustees, officers, contractors and all other persons or entities associated
with it (referred to below as “VW”), I agree and acknowledge as follows:
Although VW has taken reasonable steps to provide me with appropriate equipment and
skilled staff for the activity for which I have applied, I acknowledge that the
activities of the program have risks, including certain risks that cannot be eliminated
without destroying their unique character. Those same elements can cause loss or damage
to my equipment, accidental injury, illness, or in extreme cases, permanent trauma,
disability or death. I understand that VW thinks it is important for me to know in
advance what to expect and to be informed of the activities' inherent risks.
I agree to assume responsibility for the inherent risks of the activities for which I
have chosen to participate in. My participation in this activity is purely voluntary,
no one is forcing me to participate, and I elect to participate in spite of and with the
knowledge of the inherent risks.
Equipment
Participants are responsible for all equipment entrusted to them. Participants will be
charged for all equipment lost or damaged.
Insurance
You are covered by a Special Accident policy that will ONLY provide for EMERGENCY
MEDICAL TREATMENT. The limit is MUR 50,000. It is strongly advised to have a separate
insurance.
AGREEMENT OF INDEMNITY AND RELEASE
I (referred to as "I" or "me" in the paragraphs which follow), or, if I am under the age
or 18, my parents or guardian (referred to as "we"), for themselves and on my behalf,
agree as follows:
a)

To release and discharge VW, from all claims, liabilities and losses whatsoever
asserted by or on behalf of me, or by my parents or guardian, in any way arising
from or connected with my enrolment or participation in an activity of VW
(including transportation and occurrences to and from the activity).
I (or we) understand that in signing this document, I (or we) surrender our
rights to make a claim or file a lawsuit against VW for personal injury, property
damage, wrongful death, products liability (including strict liability), or under
any other legal theory, except in cases of intentional wrongs or the gross
negligence of VW.

b)

To defend, hold harmless and indemnify VW from any claim, and from any liability,
loss, damages or expenses (including attorney’s fees) resulting from a claim,
brought by a fellow participant, rescuer or any other person for loss or damage
caused in whole or in part by my conduct.

THE PARTICIPANT UNDERSTANDS AND AGREES TO THE ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS,
AGREEMENT OF RELEASE AND INDEMNITY ABOVE.

Signature :_________________________________________ DATE: _______/_________/_______
NAME

: _________________________________________Time :_________________

Vertical World Ltd - Assumption of Risks – Release 3.2002