Our Practice
Mountain Land Partners
Mountain Land Physical Therapy
Registered Physical Therapists
Therapy West Physical Therapy
Superior Physical Therapy
Diagnostic Solutions
Meet Our Team
MLPT Team
TW Team
RPT Team
SPT Team
DS Team
Testimonials
Orthopedic Residency
Charities
What We Treat
Body Region
Head
Neck
Shoulder
Upper Back
Lower Back
Hip
Pelvic
Hand
Wrist
Elbow
Knee
Foot
Ankle
Other Conditions
Amputee Therapy
Arthritis
Balance & Vertigo
Car Accidents
Chronic Pain
Concussion
Dance Injury
Fibromyalgia
Gait Disorders
Geriatric Conditions
Headache
Joint Replacement
Lymphedema
Men’s Pelvic Health
Multiple Sclerosis
Neurological
Pediatric Conditions
Pelvic Floor
Personal Injury
Post Surgical Rehabilitation
Sciatica Pain
Spinal Cord Injuries
Back Pain
Sports Injuries
Stroke
TMJ
Torticollis
Whiplash
Womens Health
Work Injuries
WorkReady
How We Treat
Aquatic Therapy
Blood Flow Restriction
Cryotherapy
Cupping
Diagnostic Ultrasound
Dry Needling
Electrical Stimulation Therapy
EMG & Nerve Conduction Testing
Ergonomic Training
Fascial Distortion Model
Graston Technique & IASTM Therapy
Home Rehabilitation Services
Hydroworx
Kinesiotaping
Occupational Therapy
Shockwave Therapy
Somatosensory Evoked Potential Study (SSEP)
Speech Language Pathology
Therapeutic Massage
Running Video Analysis
Locations
For Patients
Pay Your Bill
FAQs
Testimonials
Insurance
First Visit Info
No Surprises Act
Direct Access
Refer a Friend
Blog
Podcasts
Contact Us
Careers
Frequently asked questions
Home Page
Idaho
Insurance
Join our team
Location Finder
Media Release Form
Montana
Mountain Land Charities
No Surprises Act
Orthopedic (Orthopaedic) residency
Patient Testimonials & Success Stories
Pay Online
Podcasts
Privacy Policy
Recovery that moves you
Referral Center
Sitemap
Terms of Use
Utah
What we treat
What we treat old
Book Appointment
Adaptive Ski Day Waiver
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Participant/Parent or Guardian Information
Are you the Participant or the Parent or Guardian
Participant
Parent or Guardian
Volunteer
Name
*
First
Last
Date of Birth
*
Email
*
Phone
*
Address
*
Address Line 1
Address Line 2
City
— Select state —
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Facebook Handle
Instagram Handle
TikTok Handle
Child Participant (if applicable)
Minors Name
*
First
Last
Minors Date of Birth
*
I agree to the following:
*
Waiver of Liability
For purposes of this Release Agreement, the Adaptive Ski Day Event, including all associated activities, programs, transportation, instruction, demonstrations, volunteer activities, and use of any property or venue utilized for the Adaptive Ski Day Event, shall hereinafter be referred to as the “Event.” Last Chance Lakes, Southern Shores, and any other property or venue utilized for the Event shall collectively be referred to as the “Event Locations.” The undersigned hereby acknowledges they are not under the influence of alcohol or any illicit or prescription drugs that would in any way impair their ability to safely participate in the Event. It is the undersigned’s responsibility to determine whether they are sufficiently fit and healthy enough to participate in the Event and they are responsible for their own safety and well-being at all times and under all circumstances while attending or participating in the Event at any Event Location. As consideration for being permitted to use the facilities or to participate in any activity at the Event Locations, the undersigned hereby acknowledges that the activities performed at the Event Locations could be dangerous and involve risk of serious injury, death, and/or property damage. Water skiing, wakeboarding, tubing, and other water sports conducted at the Event Locations may involve high speeds close to shore and docks, in narrow channels around islands, and in generally shallow water and are inherently dangerous. In addition, from time to time, individuals participating in activities at the Event Locations may experience Swimmer’s Itch, also called Cercarial Dermatitis, which can be found in some Utah lakes and reservoirs. Information about Swimmer’s Itch can be found at https://www.cdc.gov/parasites/swimmersitch/index.html. The undersigned hereby acknowledges and assumes the risks and dangers associated with participation in the sport of water skiing, wake sports, and related water sport disciplines and activities, including without limitation, the potential for serious bodily injury, sickness and disease, permanent disability, paralysis, and loss of life; loss of or damage to equipment or property; exposure to extreme conditions and circumstances; contact with other participants, spectators, boats, animals, or other natural or manmade objects; dangers arising from adverse weather conditions; imperfect ski course conditions; water and surface hazards; equipment failure; inadequate safety measures; participants of varying skill levels; situations unknown to or beyond the immediate control of Event Organizers; and other undefined, not readily foreseeable, and presently unknown risks and dangers (“Risks”). The undersigned understands these Risks may be caused in whole or in part by their own actions or inactions, the actions or inactions of others participating in the Event, or the negligent acts or omissions of the Released Parties defined below, and hereby expressly assumes all such Risks and responsibility for any damages, liabilities, losses, or expenses incurred as a result of participation in the Event. The undersigned willingly and voluntarily performs said activities and has not been coerced in any way to participate in any activities and hereby assumes full responsibility for the risk of bodily injury, death, or property damage and, by signing below, releases, discharges, and covenants not to sue the following parties: Mountain Land Charities, Mountain Land Partners and each of its parent, subsidiary, and affiliated companies; Last Chance Lakes HOA; Southern Shores HOA; the owners, operators, managers, and property owners of Last Chance Lakes, Southern Shores, and any other Event Locations; boat owners and operators; employees; and volunteers (individually and collectively, the “Released Parties” or “Event Organizers”), with respect to any liability, claim(s), demand(s), cause(s) of action, damage(s), loss, or expense (including court costs and reasonable attorneys’ fees) of any kind or nature (“Liability”) which may arise out of, result from, or relate in any way to participation in the Event, including claims for liability caused in whole or in part by the negligent acts or omissions of the Released Parties, and will indemnify, defend, and hold harmless each of the Released Parties and Event Organizers from any such claims, demands, liabilities, losses, expenses, or damages that may be incurred as a result of such claims. The undersigned further expressly agrees that the foregoing release is intended to be as broad and inclusive as is permitted by law in the State of Utah and that if any portion is held invalid, it is agreed that the balance shall continue in full force and legal effect. THE UNDERSIGNED HAS READ, FULLY UNDERSTANDS, AND VOLUNTARILY SIGNS THIS RELEASE AGREEMENT, and further agrees that no oral representations, statements, or inducements apart from this agreement have been made.
I agree to the following:
*
Photo Release
The undersigned hereby grants full permission to Mountain Land Charites, Mountain Land Partners and each of its parent or subsidiaries and affiliated companies to use their image (photographs and/or video) for use in all media publications. The undersigned hereby waives any right to inspect or approve the finished photographs or electronic matter, and also waives the right to royalties or other compensation arising from or related to the use of the image or video. The undersigned further expressly agrees that the foregoing release is intended to be as broad and inclusive as is permitted by law in the State Of Utah and that if any portion is held invalid, it is agreed that the balance shall continue in full force and legal effect. THE UNDERSIGNED HAS READ, FULLY UNDERSTANDS, AND VOLUNTARILY SIGNS THIS RELEASE AGREEMENT, and further agrees that no oral representations, statements or inducements apart from this agreement have been made.
Signature
*
Clear Signature
Date
*
Sign Waiver
Contact Us
Search
Book an Appointment