Name:____________________________________

Address:__________________________________

City, State, Zip:_____________________________

E-mail:____________________________________

Phone #:__________________________________

ER Contact Name:___________________________

ER Contact Phone #:_________________________

Medical Conditions:__________________________
_________________________________________

Prescriptions:_______________________________
_________________________________________

Activities of Interest:__________________________
_________________________________________
_________________________________________

The Q.C Women’s Outdoor Club assumes no responsibility for personal injury, damaged equipment, theft or loss taking place on any club activities, which it sponsors. All members participate at their own risk. Anyone under age 16 must be accompanied by a responsible adult. A parent or guardian must sign for all applicants under age 18. All applications must be signed, and in signing the liability release, the applicant agrees to the above conditions.

Signature:________________________Date:________