Name of Participant *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Emergency Contact Phone # *

(###)

###

####

Liability Release. *

You are responsible for your own well-being and safety on this walk. 1. I acknowledge that outdoor activities in natural areas entail known and unanticipated risks that could result in injury. 2. I agree and promise to accept responsibility for my own safety and well-being during this activity. I understand that I may at any time opt to not participate in any part of the activity should I feel that it is not safe, or simply that I do not want to participant for any reason. 3. I voluntarily release and hold harmless Mother the Earth and the Association of Nature and Forest Therapy Guides and Programs (ANFT) and the individuals who are acting as guides on this walk from any and all claims of liability which are in any way connected with my participation in this activity. 4. If I have a medical condition or health concern that I think the guides should be aware of, I will verbally inform them at the beginning of the walk.

Yes, I agree to the above conditions

No, I do not agree to the above conditions

Model Release *

With your permission, Mother the Earth may take photographs of you and your group on this walk. We would like your permission to use these photographs in promotional materials which may include social media, website, printed flyers and books, and videos. We are sometimes asked by news reporting agencies and publications to provide photos for articles they are writing about nature connection topics. We do this at no charge. We promise to carefully select photographs that show you in a way that we are confident you will like. If you are not comfortable with having photos that include you taken and possibly used in these ways, we prefer that you mark “No” in the box below; we want for you to have a relaxed and stress-free experience on your walk.

Yes, you may take photographs of me and use them as described above

No, I prefer not to be photographed

Do you have allergic or anaphylactic reactions to any insults, such as environmental substances, foods, drugs, insect bites or strings? *

Yes

No

If you walked on the level for a mile at an average pace would you get out of breath, have pains in the chest, develop muscle fatigue or have pains in your legs? *

Yes

No

Do you have any other health-related disease, condition, or concern that program guides should be aware of? *

Yes

No

Date *

MM

DD

YYYY