Registration – TA Online

Therapeutic Adventures, Inc.

Thank you for choosing to participate. In order to personalize your experience and have a clear user profile, we need you to fill out the registration form below. Your data is safe with us! Only fully completed forms are accepted.

Name

First

Middle

Last

PARTICIPANT INFORMATION

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male
Female

Date of Birth

National/Ethnic Origin

Branch

Rank

or Phone AND

Location & Date of Injury

Height

Weight

Home Phone

Cell Phone

Email

Drivers License (# and State)

Required for state fishing permits – 16y/o and older with a drivers license

PARENT/LEGAL GUARDIAN INFORMATION

(If participant is a minor or legally incapacitated)

Name

First

Middle

Last

Address (if different from above)

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mobile Phone

Email

Emergency Contact

(Person to notify in the event of an emergency)

Primary Contact

First

Last

Phone

Secondary Contact

First

Last

Phone

REPRESENTATION OF PHYSICAL CONDITION AND PARTICIPANT INSURANCE BENEFITS

I will notify administrative staff, instructors/guides and volunteers of any medical conditions, or physical disabilities (including but not limited to: asthma allergies, [bees/food] heart conditions, blood sugar problems, seizure disorders, previous injuries or surgeries, etc.) as which may affect my ability to participate in scheduled activities. I understand and acknowledge that no major medical insurance benefits will be provided to me during this program/event. I certify that I have sufficient health, accident, and liability insurance to cover bodily injury or property damage I may incur while participating in this event and to cover bodily injury or property damage caused to a third party as a result of my participation in this event. If I have no such insurance, I certify that I am capable of personally paying for any and all such expenses or liability.

Permission to Obtain Emergency Medical Care

**In the event of a medical emergency, I authorize Therapeutic Adventures staff to hospitalize, to secure proper medical treatment, and/or order injections, anesthesia or surgery for me.

Name of Participant

First

Last

Date

Name of Parent or Legal Guardian

First

Last

Date