AM Beverage: coffee
decaf tea cocoa
Beverage: red wine white wine beer soft-drink
Any Favorite Snacks
or Beverages (water provided)
Emergency Contact / phone number:
describe your fitness level, e.g., physical activities in which you engage
(times per week, duration, and level of intensity):
HEALTH QUESTIONNAIRE: It is important that your trip leaders are alerted
if you have a conditions that could be aggravated by long, strenuous days,
or by the outdoor environment. By
obtaining some basic but pertinent medical information from you, we hope to
minimize the potential for medically related emergencies.If you respond with a “yes” to any question below, it does not mean
you will not be allowed to participate. You can, however, expect us to speak
with you about how your condition has the potential to be negatively affected
by local environmental factors or program activities. You should also be aware
that advanced medical support is often hours away. All information provided on
this questionnaire will remain confidential and will be reviewed by staff
Have you experienced an asthma attack at any time in your life? (Asthma can
potentially be affected by exercising at
’s high elevation; dry, dusty air; and wildfires)
you answered yes to question one, please answer the following as well:
you visited the emergency room because of your asthma in the last year?
you had to use epinephrine following an asthma attack in the last year?
you diagnosed with asthma in the last year?
often do you use your inhaler to treat your asthma or wheezing?
else you think we should know about your asthma:
Have you ever been diagnosed with type I or type II diabetes? (A diabetic can
easily become dehydrated in
’s very dry environment; long, arduous days/hikes can lead to hypoglycemia)
you answered yes to question two, please answer the following as well:
you visited the emergency room because of your diabetes in the last year?
you have numbness in your feet or poor circulation due to your diabetes?
you diagnosed with diabetes in the last year?
else you think we should know about your diabetes:
Have you ever visited a medical professional for a serious allergic reaction,
or have you ever been given a shot of epinephrine for an allergy or
anaphylaxis? (Some people are allergic to the following: stinging
insects found in
; iodine- used to treat drinking water and/or clean wounds; drugs used to
improve acclimatization at altitude.)
you answered yes to question three, please answer the following as well:
you had a serious allergic reaction in the last year?
you ever been given epinephrine because of your allergies or anaphylaxis?
your anaphylaxis been worsening over time?
you also have a heart condition or a history of high blood pressure?
else you think we should know about your allergies or anaphylaxis:
Have you ever received medical treatment for angina, a heart attack, or any
type of heart disorder/disease? (High altitude puts a strain on the heart, and
the altitudes at
, combined with the hiking, will almost certainly increase the heart rate of
the average visitor.)
you answered yes to question four, please answer the following as well:
you able to exert for long periods without experiencing angina pain?
you currently have congestive heart failure?
you been hospitalized within the last year because of a heart condition?
else you think we should know about your heart condition:
Have you ever been diagnosed with or are you currently being treated for high
blood pressure? (Altitude can affect blood pressure, and the environment and
physical activity associated with our programs may affect the efficacy of some
blood pressure medications.)
you answered yes to question five, please answer the following as well:
your blood pressure currently under control?
your systolic blood pressure generally under 140?
else you think we should know about your blood pressure:
Have you ever seen a medical professional following a seizure, or are you
currently being treated for any type of seizure disorder? (Some seizures are
triggered by fatigue and dehydration [which can occur following a long hike],
significant change in diet, low blood oxygen [which can occur at altitude])
you answered yes to question six, please answer the following as well:
you currently taking medication for your seizures?
you diagnosed with a seizure disorder in the last year?
is the last time you had a seizure?
else you think we should know about your seizure disorder:
Is there anything else we should know about your medical background? (I.e.,
anything that could affect your safety or ability to participate fully?)
medications have the potential to increase the risk of harm to
visitors. For example, some drugs affect a person's ability to deal with
hot/cold, while other medications can affect the body’s ability to cope with
trauma (e.g., Coumadin [Warfarin], a drug commonly used to address heart
disease, affects the body’s ability to stop bleeding).
you are taking any type of over-the-counter or prescription medication, we
encourage you to talk to your physician before coming on the trip. Please
review all of the drug’s potential side effects in order to determine
whether or not the medication could affect your well being or ability to
participate.PLEASE indicate any
medications that may affect your participation, reasons for taking, and
potential side effects here:
submitting answers to these questions, I am declaring that, to the best of
your knowledge, I have completed the questionnaire accurately. I also
understand that by knowingly filling out the form inaccurately, or by
withholding pertinent information about health, I could potentially be
increasing the risk to yourself or others.I affirm that my general health is good, that I am in good physical
condition, and that I am not affected by moderate exercise at high altitudes.
I understand and agree
that I am participating in the above trip voluntarily and at my own risk.I realize there is inherent risk in outdoor activities and will not
hold The Wild Side, LLC, or its affiliates liable for any accident that
results in personal injury, death, or property damage during or in connection
with the trip.I hereby release
and forever discharge The Wild Side, LLC, and its directors, officers, and
employees from all such claims.This
waiver will be construed according to the State of Montana.Any disputes will be governed
under Montana law and the venue of any action shall be in Bozeman,
I hereby give my
permission for The Wild Side, LLC, to procure all necessary medical help for
myself, my child or ward while said person is under the direct supervision of
The Wild Side, LLC, and grant permission to its representatives to authorize
any competent medical person to do all things reasonably necessary to take
care of any injury or sickness.There
is no health insurance or medical coverage provided.The acceptance of these terms acknowledges that the
participant/guardian accepts responsibility for payment of any medical
treatment, which may be required, while they are on this trip.
full refund of the deposit (minus $45 processing fee) will be given for all
cancellations more than 60 days before the trip. For cancellations less than
60 days before departure, the deposit is non-refundable. We cannot refund
money for missed meals, missed portions of the trip or any other unused
portions of the tour. Cancellations must be submitted in writing and are
effective upon date of receipt.
participants must fill out a medical waiver and a liability waiver.The trip requires average physical fitness and is suitable for people
of all ages. If you have health questions, consult your doctor for more
information. The tour leaders must be advised in advance of any special health
needs. Weather conditions can change without notice and it is the
responsibility of the traveler to have proper clothing and equipment. Please
contact our office for assistance in what to bring on the trip.
and Conditions: The Wild Side, LLC
acts only in the capacity of agent in all matters of transportation and tour
operation.They are not
responsible for delays, inconveniences, accidents, expense or mishap of any
kind whatsoever resulting entirely, or in part, from the negligence of others
or from causes beyond their control.They
can accept no responsibility of losses or additional expenses due to delay or
changes in air or other services, sickness, weather, strike, war, quarantine,
or other causes.All such losses
or expenses will have to be borne by the participant, as tour rates provide
for arrangements only for the time stated.The right is reserved to substitute accommodations or modes of
transportation and to make any changes in the itinerary where deemed necessary
or caused by changes in transportation schedules.The Wild Side, LLC take no responsibility for special arrangements or
problems incurred by persons physically unable to participate in the planned
activities.No refund can be made
for absence from the tour unless arrangements are made at the time of the
booking.The right is reserved to
decline, to accept or to retain any person as a tour member for any reason
which affects the operation of the tour or the rights and welfare or enjoyment
of the other tour members.The
Wild Side, LLC, will not discriminate against any individual because of race,
sex, creed or nationality.
Possession of firearms are not allowed on any The Wild Side, LLC, program.
Trips: The Wild Side, LLC, reserves
the right to cancel any trip should an inadequate sign-up make the trip
economically unfeasible for us to operate or should conditions arise beyond
our control that adversely affect the well-being of the trip members.In such a case, a full refund of the trip cost is given, but The Wild
Side, LLC, is not responsible for additional expenses incurred by members in
preparing for the trip.
Acknowledgement of Risk:In consideration of the services
of The Wild Side, LLC, business (hereinafter collectively referred to as TWS)
their officers, agents, employees, and stockholders, and all other persons or
entities associated with that, I agree as follows:TWS has taken reasonable steps to provide me with skilled guides so I
can enjoy an activity for which I may not be skilled, TWS has informed me this
activity is not without risk. Certain
risks are inherent in each activity and cannot be eliminated without
destroying the unique character of the activity. These inherent risks are some
of the same elements that contribute to the unique character of this activity
and can be the cause of loss or damage to my equipment, or accidental injury,
illness, or in extreme cases, permanent trauma or death. The
following describes some, but not all, of those risks:
the nature of the activity itself,
hiking off roads and trails,
skiing or snowshoeing off roads and trails,
moving on foot around wild animals,
weather including rain, snow, lightening, and wind,
vehicular travel, and vehicles not associated with this program
I am aware that participation entails risks of injury or death to any
participant. I understand the description of these inherent risks is not
complete and that other unknown or unanticipated inherent risks may result in
injury or death. I agree to assume and accept full responsibility for the
risks identified herein and those inherent 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 and with full knowledge of
the inherent risks.I acknowledge
that the staff of TWS has been available to more fully explain to me the
nature and physical demands of this activity and the inherent risks, hazards,
and dangers associated with this activity.I certify that I am fully capable of participating in this activity.
Therefore, I assume and accept full responsibility for myself, including all
minor children in my care, custody, and control, for bodily injury, death, or
loss of personal property and expenses as a result of those inherent risks and
dangers identified herein and those inherent risks and dangers not
specifically identified, and, as a result of my negligence in participating in
this activity.I have carefully
read, clearly understand and accept the terms and conditions stated herein and
acknowledge that this agreement shall be effective and binding upon myself, my
heirs, assigns, personal representative and estate and for all members of my
family, including minor children (under 18 requires signature of parent or
have been fully advised of the potential risks involved in participating in
enter into this agreement freely and by ACCEPTING I agree to the terms and
conditions, participant waiver, medical release, firearms policy, and
acknowledgement of risk.