Course(s) or Program in which you are participating: _____________________________
Name____________________________________________________Gender M F
In Case of Emergency, contact:
Relationship to you___________________________________________________
Dietary Needs or Preferences:
Allergies or other medical conditions:
Please read the liability waiver on the reverse side and sign it or obtain the required signature. Please send this form at least 7 days before your scheduled arrival at Blakely Island to:
Mr. LeRoy N. Hubbert, Resident Manager
Blakely Island Field Station
P.O. Box 5273
Blakely Island, WA 98222
The undersigned (student, employee, researcher, parent, invitee, or etc.) understands that the Seattle Pacific University Blakely Island Field Station (BIFS) is located on a remote island in the San Juan Islands. As such, the facilities are primitive, the surrounding terrain and waters are dangerous, and immediate medical attention is not available. I understand the above and hereby assume the risks occasioned by my (my child’s) use of BIFS facilities and participation in BIFS programs, including any and all injuries to person or property.
In consideration of the agreement by BIFS to let me (or my child) use BIFS facilities and participate in BIFS programs, I hereby release, on behalf of myself, my child, and our heirs, successors, and assigns, Seattle Pacific University and Blakely Island Field Station, as well as its officers, agents, and employees, from any claim, liability, or demand whatsoever, including without limitation, bodily injury, personal injury, sickness, disease, death, property loss or damage, or any other loss or damage of any kind, which may arise out of or in any manner be connected with my (my child’s) use of BIFS facilities or participation in BIFS programs, whether resulting from negligence or from some other cause.
This statement and agreement shall not relieve BIFS of its reasonable obligation to avoid wanton or willful acts which may lead to damage or injury; however, it represents a complete waiver of any and all warranties regarding the content and safety of BIFS facilities and programs.
Parent or Guardian Date
(if participant is under 18 years of age)