UAYCEF Trip Waiver

Name:__________________________ New Member: ___ Renewal:___

Address:_____________________________________________________

City: ____________________________ State:_______ Zip: _________

Country: __________________________

Phone: (Home) __________________ (Work)_____________________

Email: _____________________________________________________

Mobile Phone/Pager:_________________ Fax: ___________________

Sex: ______ Date of birth: ___________ Height:______ Weight: ____

Emergency contact person: ____________________________________

Relationship: ________________________________________________

Address: ____________________________________________________

Phone:___________________ Email: ___________________________

Primary grotto: ___________________________ NSS#: __________

I, _________________________________, with address or residing at

__________________________________, hereby release the National Speleological Society, UAYCEF, their officers and members, vehicle owner and driver, and property owner, cave owner and employees, and others on trips, of all liability of whatever nature might be incurred during, or as a result of a cave trip. I understand the safety practices of the Society and will abide by them. NOTE: (If under 21 years of age, parent or guardian must also sign below).

Signed ________________________________ dated:_______________

Parent or Guardian ______________________ dated _____________

Please return this waiver to: UAYCEF,C/O Chris Nicola, 2446 43 Street, Astoria, NY 11103

ver. 6/15/04