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Kayak Kaua'i

Over 24 years of celebrating and sharing the Kaua'i outdoors!

Multi Day Client Application

Note:
Before submitting electronically. fill in and print this Form.

Name of Trip:

Discovery Tour

Departure Date:
Participant's Name(s):
Address:
City:	State: Zip:
Home Phone:
Work Phone:
e-mail:
age: sex: weight: height:

Outdoor Background (Please Describe)

How did you hear about Kayak Kaua'i?

Trip Rating Select "Moderate" unless you are on a Custom Tour.
Leisurely: Means there is no strenuous paddling or hiking or other physical activity.
Moderate: You should be in good physical shape and prepared for travel in rugged conditions. The sea kayaking may involve a long day.
Strenuous: Extensive paddling or hiking. Some portions require excellent stamina, fitness, and endurance.

Medical Certificate of Good Health

Good health and being physically fit are prerequisites for any KK adventure journey. Participants who are not in good health or have serious chronic medical conditions could potentially create dangerous situations by being present. Please answer the questions below and ist any health problems. A physician's signature is required if the trip is rated strenuous, or the trip member is 65 years old or older. Part 2 is to be completed by a physician. We may wish to discuss any health related problem with the trip member or physician.

PART 1: This part should be completed by all trip members. Please explain any "yes" answers below.

Yes No	Do you have any significant medical illness(es) which have required the regular care of a Doctor?
Yes No	Do you have any allergies or have you had any bad reactions to any drugs? Which ones and what effects?
Yes No	Have you been hospitalized in the last five years? What for?
Yes No	Do you have or have you ever been told by a Doctor that you had: epilepsy, diabetes, high blood pressure, asthma or lung disease, ulcer, kidney stones or disease, colitis, or intestinal trouble, heart disease, any significant foot, leg or back problems,or any other disease or medical condition?
Yes No	Is there any chance that you might be pregnant at the time of the selected trip?

Explanation of any "Yes" answers above:

Part 2: To be completed by a physician (only if you are age 65 or older and/or the trip is rated strenuous) and mailed to: KayakKaua'i, P.O. Box 508, Hanalei, HI 96714

Note to Physician: Please read the definition of trip rating and the trip itinerary to get a feel for the level of physical fitness required. Discuss the level of activity required with your patient.

The applicant named herein _________________________________________ age _______, has been examined by me and found to be physically qualified to participate in a trip of the grade indicated.

Medical facilities on a KK trip may not be available. I have discussed the above matters with my patient.

Signature of the Physician _____________________________________ Date____________________

Name and address of physician _______________________________________________________

________________________________________________________________________________

List any special Dietary requirements:
Let us know of any preferences (Coffee or tea, cavorite soft drink, wine or beer)

In case of emergency contact:
Relationship:
Address:
Day Phone:
Evening Phone:

PLEASE READ CAREFULLY!
This is the part you need to sign and mail to us
Liability Release and Assumption of Risk Agreement.

In consideration of being allowed to participate in any way in the Kayak Kaua'i program, its related events and activities, I / we, ________________________________________, the undersigned, acknowledge, appreciate, and agree that:

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of Kayak Kaua'i immediately; and,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Kayak Kaua'i, its partners, officers, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Please initial __________

I have carefully read this agreement. I understand that it is a release of liability and a contract between me and Kayak Kaua'i and/or its contracted tour operators or affiliated organizations and sign it of my own free will. I also acknowledge that I have carefully read Kayak Kauai's reservation information (30% deposit required to confirm a reservation and balance of trip fees due 30 days prior to departure date), including its policy on cancelled trips and refunds ($100.00 processing fee for cancellations prior to 30 days before departure and 30% cancellation charge for cancellations within 30 days of departure), and agree to all stated conditions set forth in the reservation information.

Participant's Signature ______________________________________________ Date _____________

After filing in this form, please remember to also ... print this Form before clicking the submit button below.
Please mail printed form to:
Kayak Kauai
P.O.Box 508, Hanalei, HI 96714

Kayak Kaua'i ©
P.O. Box 508
Hanalei,Hi, 96714
Fax: (808) 826-7378
Tel: On Kaua'i (808) 826-9844
Tel: Off Island (800) 437-3507