Name:______________________________________________________

           Address;______________________________________________________

 Society (Club).______________________________________________________  

 Please read, the following information before beginning the trip. Sign and date this form to acknowledge that you have read and understood the information presented.

 I understand that the field trip or activity that I am participating in may include one or more of the following hazard(s) that may result in personal harm: 

• Unpredictable and dangerous Environmental Conditions/Hazards including, but not limited to snow; rain; wind; very cold and very hot temperatures; lightning; altitude; loose rock; falling rock; avalanche; river hazards, mud slides; mud; ice, and other slippery conditions.
• Dehydration, heat prostration and sun stroke;
• Wild animals including bears, dogs, etc.;
• Poisonous animals/insects including ants, bees, snakes scorpions, spiders, etc.;
• Irritating/sticky bushes and plants including poison ivy, poison oak, poison sumac , etc.;
• Active or abandoned mine workings including adits (tunnels), shafts, which may be uncovered, or covered with rotten timbers, etc.
• l understand the risks inherent in all outdoor activities (including high altitude activities) existing in the environment, either natural or man-made.
  

By participating, I am assuming the risks inherent in this field trip or activity and am releasing the above named Society of The Southeast Federation of Mineralogical Societies, Inc, from any liability for claims or lawsuits by the undersigned participant arising out of this field trip or activity.

 By signing this waiver of liability, you understand that you release all of the property owners (private land owners and mining claimants) and lessees (oil and gas and grazing allottees) of stay and all liability or responsibility for any accidents, injuries, problems or any other unfortunate incidents that may occur during your collecting activities on their property. Also, commercial collecting is not allowed.

 I have read all of the aforementioned information and understand any and all of it. Any questions which have occurred to me have been answered to my satisfaction. I am participating in these activities of my own free choice.

 If the participant is under 18, this form must be read and signed by parent or legal guardian before participating in this field trip or activity.

 
__________________________________________________      _________________ 
Signature of Participant                                                                           Date

 __________________________________________________      _________________
Signature of Witness                                                                                Date

 __________________________________________________      _________________
Signature of parent or Legal Guardian                                                Date