REGISTRATION and WAIVER
LSART BOOT CAMP TRAINING
March 21-24, 2016
Full Name: (Dr., Mr., Ms.)
Organization: Title:
Mailing Address:
City: State: ZIP:
Work Phone: Cell Phone:
Home/Emergency Phone: E-Mail:
Emergency Contact & Phone:
Please Select All Dates of Attendance/Additional Items:
March 21- Large Animal Handling ($15) March 22- Technical Large Animal ($15) March 23- Slack Water Rescue ($15)
March 24- Slack Water Rescue ($15) Bootcamp T-Shirt ($12) Please indicate shirt size: _______________
Payment Type: VISA MASTERCARD DISC AMEX Check
Card Number: Expiration Date: CVV:
Name on Card: Amount to be Charged:
(for office use only)
Payment enclosed Yes No
**For the security of your data, we do not accept credit card information by email**
Please fax to 225-408-4422 or mail with payment to LSART, C/O LVMA
8550 United Plaza Blvd., Ste 1001 Baton Rouge, LA 70809
ASSUMPTION OF RISK
By signing this agreement, the undersigned, (print name) __________________________________________, acknowledges that the nature
of this training involves a high degree of risk of injury to person and property (including death) and the undersigned voluntarily accepts and
assumes such risk. These risks include, but are not limited to: strenuous physical activity; travel to, within and from rustic and/or remote areas
under rugged conditions, by plane, helicopter, truck, boat and other modes of transportation; exposure to human and animal diseases; lack of
adequate or immediately available medical care; animal and insect bites, kicks or scratches; risks associated with construction, loading and
unloading; risk of electric shock; exposure to oil and hazardous materials; and exposure to inclement weather and other natural elements. The
undersigned acknowledges and agrees that he/she is solely responsible for determining his/her ability, fitness and suitability to participate in
this training and represents to the sponsors that he/she is in good health, and is aware of no physical problem or condition that would impair
his/her ability to perform the Services.
WAIVER OF LIABILITY
The undersigned, (print name) _____________________________________, hereby releases, discharges, holds harmless and indemnifies the
sponsors, LSART and ASPCA and their affiliates and their respective members, shareholders, Operations Managers, trustees, agents, employees
and representatives from all damages, losses, injuries, liabilities, claims, demands and causes of action for personal illness or injury, death or
damage to personal property (“Claims”), in each case suffered by the undersigned, or by any other person, arising from or occurring in
connection with provision of this training, including illness, injury, death or damage caused in whole or in part by the negligence or wrongdoing
of any member of LSART or ASPCA and any illness, injury, death or damage arising out of any medical treatment or first aid provided or
procured by the sponsors. The undersigned agrees that neither he/she or his/her successors or assignees will ever assert in any forum any such
Claim, and the undersigned shall indemnify and hold harmless the sponsors from and against any such Claim (including reasonable attorneys
fees and costs incurred in defending such Claim) brought against them by any other person.
Si
gnature______________________________________________________ Date_________________
* Please make two copies of this form. Send one copy to LSART and retain a copy for your records.
Questions? Please contact us at 337-298-1636 or by email at lsartinfo@gmail.com
