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Passenger Emergency Contact and Health Form Liability Waiver
Cruise Dates: ____________________________________________
First Name:
______________________________________________
Last Name:
_______________________________________________
Address: ___________________________________________________________
City: _____________ State / Province:
____________________
Country:
________________________ Email:
_______________
Day Phone:
___________________ Cell Phone: _______________
Emergency Contact Information
Name:
______________________Relationship:
_______________
Address:
_________________________________________________
City: ____________________ State / Province:
_____________
Country:
______________________ Email:
__________________
Day Phone:
__________________ Cell Phone: ________________
Doctor’s Name:
______________________ Phone:______________
Insurance Company: ________________________________________
Policy Number:
___________________________________________
Health Information:
Please describe any known health conditions
you have that might affect you during the trip or that might affect any emergency
treatment.
In case of an emergency do you have any allergies,
religious convictions or legal arrangements that we need to know about prior to
emergency treatment? If yes please explain.
Release of Northwest Navigation Co, Inc.
and the M/V David B from liability.
I, ___________________________________ am
registered to participate on a cruise hosted by Northwest Navigation, Co. Inc. aboard
the Motor Vessel David B. I am reasonably physically fit and have disclosed all
physical pre-conditions to Northwest Navigation Co., Inc. that could be a danger
to my heath or to others. I am responsible for monitoring my ability and knowing
my limits. I hereby release Northwest Navigation Co, Inc. and its affiliates from
any and all liabilities to me with respect to injury, illness or loss.
Signature:
_________________________________________
Date: ___________
Publication and Promotion Release:
I hereby release any photograph taken of
me for use in promotions and publications for Northwest Navigation Co. Inc. and
the M/v David B.
Privacy Disclosure:
Please note that Northwest Navigation Co., Inc. Does not share any information
with other entities. All information disclosed will remain private.
