APPLICATION
Delaware Valley Chapter
LAKE DISTRICT, ENGLAND
AUGUST 6 TO 15, 2004
A. Personal Information
Name (Last, First, MI)
Occupation
AMC Membership #
AMC Chapter
Passport Number
Smoker?
Nationality
Visa Required?
Yes:
No:
Issue Date
Yes:
No:
Expiration Date
Visa Number (if not currently available,
please provide no later than June 30, 2004)
B. Information About This Trip
If the trip is full, do you wish to be on the waiting list?
Yes:
No:
Sleeping Arrangements: Leaders will attempt to meet requests as facilities permit. Additional costs may be incurred for a double
bed or an individual room. Please contact the leaders for more information. Sharing partners may be selected at pre-trip meetings.
Would you like an
individual room?
* For additional fee
Name of person with whom you’d like to room
Yes*:
No:
If sharing, would you like a double bed?
May the leaders distribute your contact information to other Participants?
Yes:
No:
How did you hear about this trip?
Have you been on a previous AMC excursion?
Yes:
No:
Please provide details:
C. Fee/Payment Information
Fee
Trip cost per person (AMC members)
$1,770
Trip cost per person (non-AMC members)
$1,810
Minimum deposit required. Balance due by May 15, 2004.
$750
Please make check payable to “Paul Davis AMC”
Check #
NON-AMC MEMBER: If you want to join the AMC, please enclose a separate check for $40
to cover the membership fee. Checks should be made payable to “AMC” Check #
Fee Enclosed
TOTAL
$40
Cancellation Policy: The leaders will refund any fees that you have paid minus expenses already
incurred or future expenses that will be incurred because of your registration that cannot be avoided.
D. Signature
Signature (If under 18 years old, must
be signed by parent or legal guardian).
Date:
Note: All information on this application must be completed. Use additional sheets, if necessary.
Page i of i
02/11/04
PREFERENCES
Delaware Valley Chapter
LAKE DISTRICT, ENGLAND
AUGUST 6 TO 15, 2004
A. Expectations
What are your expectations
for this excursion? Please be
candid so the leaders can
attempt to fulfill your desires.
Please list your 3 preferred
additions to the itinerary.
These are in case changes are
necessary.
1
2
3
B. Hiking Experience
How do you rate yourself?
Novice:
Improver:
Intermediate:
Advanced:
What is the longest day hike
you have done? Please
describe the distance, terrain
and any other important
factors.
List your AMC and nonAMC hiking experiences
C. Flight Information: The leaders will attempt to accommodate your flight preferences, but may not be able to do so. Unless
you provide alternate instructions, the leaders will check out flight prices, then contact you to discuss the options.
US Departure Airport
Preferred
Alternate
Seating Preference
Arrive Early in the UK?
(Before Aug. 7, 2004)
Meal Preferences
Yes
Depart Late from the UK?
(After Aug. 15, 2004)
No
Yes
No
Frequent Flier Information (provide additional sheets as necessary)
Airline
Frequent Flier Number
Airline
Frequent Flier Number
d. Skills: You do not need to have any of these skills. This information is requested so that the leaders can understand the skills
of the group in case of emergencies. When completing, please indicate the date of your most recent training.
Wilderness First Aid
WFA
AWFA
WFR
Other, please specify
Standard First Aid
CPR
Red Cross
EMT
Other, please specify
Medical Professional
Yes
No
Map and Compass
None:
If yes, please detail
Beginner:
Page i of i
Intermediate:
Advanced:
02/11/04
APPALACHIAN MOUNTAIN CLUB
CONFIDENTIAL MEDICAL FORM
Copies must be filled out separately for each participant
GENERAL INFORMATION: Excursion Title: Lake District, England
Name:
Phone #: Day (
Address:
Excursion Date: August 6-15, 2004
Male  Female  Soc. Security #:
Evening (
)
E-mail:
)
Street
City
State
Zip
EMERGENCY CONTACT (Parent or guardian information if participant is under 18):
Name:
Phone #: Day (
Address:
Relationship:
Evening (
)
)
Street
E-mail:
Cell/page: (
City
)
State
Zip
INSURANCE COVERAGE: Participant is responsible for his or her own medical expenses. Insurance is recommended,
but not required for participation. The information below is for the primary family policy holder.
Insurance Company:
Insurance Company Phone #: (
)
Certificate/Policy/ID #:
Group # (if applicable):
Address:
Street
City
Name of Policy Holder:
Phone #:
Address:
State
Zip
State
Zip
Soc. Security #:
Place of Employment:
Street
City
Physician/Primary Care Provider’s Name:
Phone #: (
)
MEDICAL AND PHYSICAL INFORMATION:
Date of Birth:
/
/
Age:
Height:
Weight:
Date of Last Tetanus Booster:
EXERCISE: Detail your current activity level below –or–  None
(AMC recommends within 10 years)
Activity
Frequency per Week
Approximate Time/Distance
Intensity Level
SWIMMING ABILITY:  Cannot swim
ALLERGIES:
 Can swim 100 feet  Can swim 500 feet  Strong swimmer
Please list all allergies including medicines, food,
–or–
 No Allergies
Allergy
bites, stings, shellfish, iodine, plants, and animals
Reaction
Medication Required
MEDICATIONS: Please list all prescription and non-prescription
Medication you take and/or carry with you.
Medication
Condition
Dosage (amount/frequency)
–or–
 No Medications
Initiated (month/year)
Side Effects
DIETARY RESTRICTION: Please be specific (vegetarian, no red meat, vegan, lactose intolerant, food allergies, strong
dislikes, etc.)
PLEASE COMPLETE THE NEXT PAGE/REVERSE SIDE>>>
Page i of ii
12/01/02
APPALACHIAN MOUNTAIN CLUB
CONFIDENTIAL MEDICAL FORM
Copies must be filled out separately for each participant
HEALTH HISTORY: Please check the appropriate boxes and respond to all questions below.
Yes No
Yes No


1. Operations/Serious Injuries in the past five years?


9. Neck/Back/Knee/Shoulder/Ankle problems?


2. Hospitalizations/Emergency Room visits in the past year?


10. Bleeding disorders, anemia?


3. Diabetes: Please note below if participant is insulin dependent. 

11. Pregnant: If yes, what trimester?


4. Epilepsy or seizure disorder: If yes, date of last seizure:


12. Does participant smoke?


5. Other past or current medical issues/illness/requirements?


13. Asthma or other respiratory problems?


6. Heart attack/By-pass surgery/Angioplasty/Angina/Unexplained fainting?


7. Other cardiac conditions, including heart murmur or irregular heartbeat?


8. High blood pressure, even if being treated with medication: If yes, list BP with date from last doctor’s visit below.
IF PARTICIPANT IS UNDER 18, PLEASE COMPLETE THE FOLLOWING


14. Has the participant had counseling with a psychiatrist/psychologist/counselor within the past two years?
If YES, is it currently ongoing? Yes  No 
Additional Emergency Contact (Other than parent or guardian listed on previous page):
Name:
Phone #: Day (
Address:
)
Street
Relationship:
Evening (
)
E-mail:
Cell/page: (
City
)
State
Zip
If any of the boxes above were checked yes, please provide a description including history, symptoms, hospitalizations, and
any restrictions. Please refer to the number listed by the issue above, and attach additional pages as necessary. Be sure to
detail any medications on the previous page.
Are there any physical or medical conditions not listed above which may affect participation?
If YES, please explain (attach additional sheets as necessary):
Yes 
No 
PLEASE READ CAREFULLY:

Please review this form to be certain you have completed every question. This complete Medical Form is required
participation in this AMC program.

All information on this form is confidential. It is possible to complete many AMC programs with a variety of
medical/psychological difficulties, but the AMC must be aware of these conditions. Failure to disclose medical
history information as requested could result in serious harm to you and other participants in your program.

The status of your participation will be determined after review of this form. In some case further evaluation,
possibly including consultation with your health care provider, may be necessary.
SIGNATURE REQUIRED
Consent is hereby given for the applicant to attend an Appalachian Mountain Club program. Permission is given for AMC
staff, volunteers, representatives or contractors to obtain or provide medical care for me/my child, or to transport me/my child
to a medical facility. I further authorize AMC staff, volunteers, or other medical personnel to render such treatment they
consider necessary for my/my child’s health and I agree to pay all costs associated with that care and transportation. I have
read and understood both pages of this medical form and the information I have provided is, to the best of my knowledge,
correct and complete:
Applicant’s signature
Date
Signature of parent/guardian (if applicant is under 18)
Date
Page ii of ii
12/01/02
AMC VOLUNTEER-LED INTERCHAPTER EXCURSION
ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS & RELEASE
AND INDEMNITY AGREEMENT
Copies must be filled out separately for each participant
TRIP Lake District, England, Aug. 2004 TRIP #
LEADER Paul Davis
CO-LEADERS Diane Carroll, Bob Cooper
INTRODUCTION
PLEASE READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING. All participants must sign this Document. For
participants under 18 years of age, one or both parent(s) or legal guardian(s) must also sign. Throughout this Document, participants
under 18 years of age will be referred to sometimes as ‘minor’ or ‘child,’ and parent(s) and guardian(s) will be referred to collectively as
‘parent(s).’ In consideration of the services of the Appalachian Mountain Club, Inc., a charitable, not-for-profit corporation, organized and
existing under the laws of Massachusetts, and its chapters, including all officers, employees, representatives, independent contractors,
volunteers (including leaders and co-leaders), members and all other persons or entities associated with it (collectively referred to in this
Document as ‘AMC’), participant and parent(s) of a minor participant acknowledge and agree as follows:
AMC contracts with individuals or organizations that are independent contractors (not employees or agents of AMC) to conduct certain
activities participant may be engaging in. Although AMC has made reasonable efforts to locate responsible contractors, these contractors
work independently. AMC does not supervise or control these independent contractors and is not legally liable or responsible for their
conduct. Further, AMC uses volunteers to assist with and lead its trips and excursions. These individuals are not paid professional
guides or leaders. In all activities, all participants share in the responsibility for their own safety and the safety of the group.
ACKNOWLEDGMENT & ASSUMPTION OF RISKS
AMC volunteer-led inter-chapter excursions can take place within the U.S. Activities include, but are not limited to hiking, backpacking,
camping, biking, skiing, trail maintenance, mountaineering, rock and ice climbing, canoeing, kayaking, sailing, swimming, snorkeling, and
transportation or travel to and from activities (referred to in this Document as ‘activities’ or ‘these activities’). I (and my parent(s), if I
am a minor) acknowledge that the inherent and other risks, hazards and dangers of these activities can cause or lead to injury,
property damage, illness, mental or emotional trauma, disability or death to participant or others. The following includes some,
but not all of those risks, hazards and dangers:
Risks present in an outdoor, mountainous or wilderness environment on land or water, both on and off trail. Travel can be subject
to storms, strong winds, high altitudes, avalanches, flashfloods, currents, waves, whitewater, lightening, rapidly moving rivers or other
water bodies, stream crossings, snow or ice, extremely hot, humid or cold weather or water, falling rocks, wild animals, disease carrying or
poisonous animals or insects and other natural or man-made hazards and dangers. Hazards may not be marked and weather is
unpredictable year-round.
Risks associated with travel in a foreign country, such as political unrest, terrorism and warfare, contact with unusual diseases, exposure
to contaminated food or water, dangerous road or travel conditions, thievery and other hazards not encountered in the U.S. Participants
may be subject to laws and legal systems that do not provide the same protections as the U.S legal system. Foreign vehicles may not meet
U.S. safety standards.
Risks in decision making, including, without limitation, the risk that an AMC staff member, volunteer, representation, co-participant or
contractor may misjudge a participant’s capabilities, or misjudge weather, terrain, water level, or route location.
The risk that equipment used in an activity may be misused, or may break, fail or malfunction.
AMC activities may take place in remote places, several hours or days from medical facilities, causing potential delays or difficulties
with communication, transportation, evacuation and medical care. Medical facilities may be primitive, inadequate or inaccessible.
Risks connected with cooking and camping chores. Participants may cook over a gas store or an open fire and are subject to the risk of
gas explosion or burn. Water may be contaminated and must be disinfected before use.
Risks associated with transportation. Travel can be on foot or by vehicle, aircraft, train, taxi, bicycle, animal, boat or other means and
can be over rough and unpredictable terrain or via oceans, lakes or rivers, with wind, rain or other adverse weather conditions.
Risks involved in riding or dealing with animals, including without limitation, horses, donkeys, llamas or camels. Animals are
unpredictable in all circumstances, whether participants are mounting, dismounting, saddling, riding, or dealing with animals in any way.
Without warning, animals can kick, bite, stomp, read, fall down, and react to the environment, people, other animals or objects. Risks
include equipment that may fail, saddles that may slip and other riders who may not control their animals.
Risks regarding conduct, including the potential that the participant, or other participants or third parties (for example, rescue squads,
medical facility) may act carelessly or recklessly.
Other risks, hazards and dangers that are generally associated with educational and/or adventure activities.
These and other risks, hazards and dangers may result in participants: falling, being struck, colliding with objects or people,
experiencing vehicle or boat collision or capsize, drowning, reacting to high altitudes, weather conditions or increased exertion,
suffering gastro-intestinal complications or allergic reactions, becoming lost or disoriented, or experiencing other problems. These
and other circumstances may cause hyperthermia, hypothermia, frost bite, dehydration, burns, high altitude sickness, heart or
lung complications, broken bones, concussions, paralysis, or other injury, damage, death or loss.
PLEASE COMPLETE THE NEXT PAGE/REVERSE SIDE>>>
Page i of ii
12/01/02
AMC VOLUNTEER-LED INTERCHAPTER EXCURSION
ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS & RELEASE
AND INDEMNITY AGREEMENT
Copies must be filled out separately for each participant
I (participant and parent(s) of a minor participant) acknowledge:

I have accurately completed the AMC application and medical forms and reviewed and understood all AMC program information and
materials received;

AMC representatives are, and have been available, should I have further questions about the nature and physical demands of these
activities and the risks, hazards and dangers associated with these activities;

AMC staff, leaders or other personnel cannot assure participant’s safety or eliminate these risks.
Participant takes responsibility for having appropriate skills, physical conditioning, equipment and supplies for these activities.
Participant is voluntarily participating with knowledge of the risks. Therefore, participant (and parent(s) of minors) assume and
accept full responsibility for the inherent and other risks of these activities (both known and unknown), and for any injury,
damage, death or other loss suffered by participant (and parent(s) of minors), resulting from those risks and resulting from
participant’s negligence or other misconduct.
RELEASE AND INDEMNITY AGREEMENT
Please read carefully. This Release and Indemnity agreement contains a surrender of certain legal rights. Certain federal land
agencies do not allow service providers to be released by their clients from liability for injuries or other losses occurring while operating
under permit on those federal lands (‘restricted federal lands’). Therefore, except to the extent federal rules or regulations prohibit my
doing so on restricted federal lands, I (adult participant and/or parent(s) of a minor participant) agrees as follows:
(1) to release and agree not to sue AMC, with respect to all claims, liabilities, suits or expenses (including attorneys’ fees and
costs) (hereafter collectively ‘claim’ or ‘claims’), in any way connected with my/my child’s enrollment or participation in these
activities, or use of AMC equipment or facilities. I understand I agree here to waive all claims I may have against AMC,
and agree that neither I, nor anyone acting on my behalf, will make a claim against AMC, as a result of any injury,
damage, death or loss suffered by me or my child;
(2) to defend and indemnify (‘indemnify’ meaning protect by reimbursement or payment) AMC, with respect to all claims brought
by or on behalf or me, my child, my family member, a co-participant, or any other person in any way connected with my/my
child’s enrollment or participation in these activities or use of AMC equipment or facilities.
This Release and Indemnity Agreement includes any losses caused or alleged to be caused, in whole or in part, by the negligence of
AMC (but not its gross negligence or intentional or reckless misconduct), and includes claims for personal injury, property
damage, wrongful death, breach of contract or otherwise.
CONCLUSION
I (participant and parent(s) of a minor participant) agree that the substantive laws of the Commonwealth of Massachusetts govern this
Document and all other aspects of my relationship with AMC, and that any mediation, suit, or other proceeding must be filed or entered
into only in Massachusetts.
AMC reserves the right to improve any participant from the program who staff or leaders believe, in their discretion, presents a safety
concern or medical risk, is disruptive, or acts in any manner detrimental to the program. If participant is dismissed or departs for any
reason, participant (and his or her family) are responsible for all costs of early departure whether for medical reasons, dismissal, personal
emergencies or otherwise. These costs include, but are not limited to medical evacuation and costs, plane, train or taxi fare,
accommodations, and costs and compensation for staff accompanying participant.
Any portion of this Document deemed unlawful or unenforceable shall not affect the remaining provisions, and those remaining
provisions shall continue in full force and effect.
Participants and parent(s) of minor participants agree: I have carefully read, understood and voluntarily sign this Document and
acknowledge that it shall be effective and binding upon me, my minor children and other family members, and my heirs, executors,
representatives and estate. One or both parents must sign below for any participating minor (those under 18 years of age).
Signature of Participant
Date
Print Name
Signature of Parent of Participating Minor
Date
Print Name
Signature of Parent of Participating Minor
Date
Print Name
Page ii of ii
12/01/02
INSURANCE
Delaware Valley Chapter
INSURANCE ACCEPTANCE/DECLINE
TRIP:
TRIP NUMBER
LEADER
CO-LEADERS
Lake District, England, August 6-15, 2004
Paul Davis
Diane Carroll, Bob Cooper
The leaders of this trip recommend that our participants purchase travel insurance to protect
themselves against financial loss in the case of personal emergency or other unforeseen events.
Each participant is responsible for his or her decisions regarding travel insurance, including
whether to purchase insurance, type of insurance, and choice of insurance company.
Furthermore, some travel insurance is time-sensitive and needs to be purchased at and/or shortly
after you apply to join this trip.
Participants can change this decision at their own discretion. If changes are made, participants
should inform the leaders of this trip of their new plans.
Please choose the option that you have selected:

I have travel insurance with

I do not currently have travel insurance but plan to purchase travel insurance. I am aware
that by delaying my purchase, I may be ineligible for some types of insurance.

I have not taken and do not plan to take travel insurance
Name:
Signature:
Date:
Page i of i
12/01/02