Fly Fishing New England Client Registration & Safety Form Please complete this form before your trip or class with Fly Fishing New England Contact Info * First Name Last Name Age Range 20-30 30+ Phone/Text * (###) ### #### Email * Activity * Choose one Guided Trip Fly Fishing Class Combination of both Class / Trip Date * MM DD YYYY Fly Fishing Experience Choose one 1-2 yrs 2-3 yrs 3 or more years Medical & Emergency Contact Info At Fly Fishing New England, we are committed to respecting and adhering to HIPAA laws. Any medical information provided by our clients will be kept strictly confidential and will only be shared with medical professionals in the event of a medical emergency to ensure the client's safety and well-being. Any medical conditions we should be aware of? * e.g. Diabetes, mobility restrictions, cardiac, seizures etc. Yes No If yes, please note. Do you take any medications? * Please list any relevant medications to this event such as seizure medication, insulin for diabetes etc. Yes No If yes, please note. Do you have Anaphylaxis? * Do you have Anaphylaxis to bee stings or other environmental or food sources? Yes No Please note any other relevant medical information here. Emergency Contact info * First Name Last Name Phone * (###) ### #### Relationship * Liability Waiver & Release Please review the following liability waiver & release content, then click the "I Agree & Approve" check box. Liability Waiver & Release * I understand that fly fishing involves risks (e.g., slips, weather hazards, wildlife, equipment accidents) and voluntarily assume these risks. I affirm I’m fit to participate and will bring necessary medications. I authorize staff to assist with my meds in emergencies (not as medical professionals) and to seek medical help if needed, at my expense. I release Fly Fishing New England, Stephen Rock, and affiliates from liability for injury, loss, or damage during this activity. I agree to conduct myself in a professional, respectful, and responsible manner during all activities. I will abstain from using drugs or consuming alcohol and will treat my guide, fellow participants, and the environment with courtesy and respect. I understand that failure to do so may result in my removal from the activity without refund. I Agree & Approve Photo and Social Media Release Photo and Social Media Release * I grant Fly Fishing New England and its affiliates permission to use photographs, videos, or other media taken during the activity for promotional, marketing, or social media purposes. I understand that I will not receive compensation for such use and that my name will not be disclosed without prior consent. I consent to the use of my image or likeness as described above. I do not consent to the use of my image or likeness. Thank you! We look forward to guiding and teaching you on this part of your fly fishing journey! Tight Lines!
