Student Registration Form













    Refund Policy

    In the event of student course cancellation, course payment will not be refunded. Monies paid
    will be applied to a future scheduled course date. Cancellations made within 30 days of course may be subject to a 25% reschedule fee. Mountain Shepherd, in review of certain situations, reservesthe right to refund full course payment on a per case basis.

    Payment Policy

    Receipt of full course payment by Mountain Shepherd guarantees and reserves student’s placement.
    All required forms must be completed and signed by student and received by Mountain Shepherd prior
    to student’s arrival at training area. Mountain Shepherd reserves the right to consider special
    exceptions to this payment policy on an individual student basis.

    I herby agree to t he refund policy and the payment policy

    Agree

    Health History Form








    Please complete the following regarding medical and health history:

    Are you under treatment for any illness or injury?

    YesNo

    If yes, please describe

    Do you have a history of heart problems?

    YesNo

    If yes, please describe

    Please list anything we should be aware of regarding your health

    Participation Agreement - Release and Assumption of Risk

    In consideration of the services of Signal West, Inc. dba Mountain Shepherd, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “MS”), I hereby agree to release, indemnify, and discharge MS, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

    1. I acknowledge that hiking, camping and backpacking entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

    The risks include, among other things: Slipping and falling; falling objects; water hazards; exhaustion; exposure to temperature and weather extremes which could cause hypothermia, hyperthermia, heat exhaustion, sunburn, dehydration; and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; equipment failure; and improper lifting or carrying.

    Furthermore, MS employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

    2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

    3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless MS from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of MS’s equipment or facilities, including any such claims which allege negligent acts or omissions of MS.

    4. Should MS or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

    5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

    6. I agree to pay for all damages to the facilities of Mountain Shepherd caused by my or my family’s or my company’s negligent, reckless or willful actions.

    7. In the event that I file a lawsuit against MS, I agree to do so solely in the state of Virginia, and I further agree that the substantive law of Virginia shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

    By checking "Agree" below and by submitting this form, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against MS on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.

    I agree that all the above information is true and complete. I agree to the terms of Participation Agreement above.

    Agree

    Visitor Acknowledgement of Risks

    In consideration of the services of Signal West, Inc. dba Mountain Shepherd, their officers, agents, employees, stockholders, and all other persons or entities associated with those businesses (hereinafter collectively referred to as “MS”), I agree as follows:

    Although MS has taken reasonable steps to provide you with appropriate equipment and skilled guides so you can enjoy an activity for which you may not be skilled, we wish to remind you this activity is not without risk. Certain risks cannot be eliminated without destroying the unique character of this activity. The same elements that contribute to the unique character of this activity can be causes of loss of or damage to your equipment, accidental injury or illness or, in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for this activity, but we do think it is important for you to know in advance what to expect and to be informed of the inherent risks. The following describes some, but not all, of those risks:

    Slipping and falling; falling objects; water hazards; exhaustion; exposure to temperature and weather extremes which could cause hypothermia, hyperthermia, heat exhaustion, sunburn, dehydration; and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; equipment failure; and improper lifting or carrying.

    I am aware that this activity entails risks of injury or death to myself. I understand that the description of these risks is not complete and that other unknown or unanticipated risks may result in injury or death. I agree to assume responsibility for the risks identified herein and those risks not specifically identified. My participation in this activity is purely voluntary, no one is forcing me to participate, and I elect to participate in spite of the risks.

    I certify that I am fully capable of participating in this activity. Therefore, I assume full responsibility for myself, including my minor children, for bodily injury, death, and loss of personal property and expenses thereof as a result of those inherent risks and dangers and of my negligence in participating in this activity.

    I have read, understood, and accepted the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon myself, my heirs, assigns, personal representative, estate and for all members of my family, including any and minors accompanying me. I acknowledge I am not relying on any oral, written, or visual representations or statements made by MS, including those made in its brochures or other promotional material, to induce me to participate in this activity.

    By checking "Agree" I hereby agree to the terms of the Visitor Acknowledgement of Risks outlined above.

    Agree

    If under of 18, name of parent or guardian

    If under 18, agreement of parent

    Agree

    Optional: Photo Release

    I grant to Mountain Shepherd, its representatives and employees the right to take photographs of me and my property in connection with my attendance in a survival course.

    I authorize Mountain Shepherd, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

    I agree that Mountain Shepherd may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

    By checking "Agree" I hereby understand and agree to the above Photo Release:

    Agree