Jalan Raya Singaraja – Bedugul

Desa Gitgit, Kecamatan Sukasada, Kabupaten Buleleng

No. Hp : +6285337665069 (Office)
Date : _____________________/ _______________/ 201
PARTICIPANT’S PROFILE

Please write legibly

Participant’s Family Name : ...................................................................................................................................
Date of Birth :Y M D Place : ................ Age : .............. Male Famale
Address : ...................................................................................................................................................
City : ....................................Country : ............................................Nationality : ...............................
Telephone number : ............................................................... Mobile : ................................. ...............................
Email address (required fpr you validation)

Facebook : ...................................................................................................................................................
Hotel address : ...................................................................................................................................................
Are you good health ? Yes No ..........................................................................................
Are you under in special medication ? Yes No ......................................................................
Can yo swim 25m ? Yes No ........................................................................................................
Other sport practiced are : ....................................................................................... .............................................
Height : ............ Weight : ............ Shoes size (EURO – UK – US) ............... Right-handed Left-handed

EMERGENCY CONTACT DETAIL

First Name : ............................................ Last Name : ............................................... Relationship : ..........................................
Telephone : ..........................................Email address : ................................................ Address : ..............................................

Canyoning trip /
Start date Completion date Net price Deposit Balance
Training Course

Instructor : …............................................. Assistant : ................................................. Agent : …..............................................

.
Payment by : Cash Voucher Bank transfer Cheque Credit Card (extra fees can be charged by the bank)
LIBALTY RELEASE AND ASSUMPTION OF RISK FOR CANYONING TRIP AND RESCUE TEAM TREANING
COURSE. PLEASE READ CAREFULLY BEFORE SIGNING.
I understand that participation in the above trip/training course may be hazardous for the above-named participant In
signing belong, I assume risk o f harm or injury which may occur to the participant as a result of participating in the above
named canyoning trip/training course. In the event of an adverse, unfavorable or dangerous weather, bad hydrologic
conditions or uneven terrain during the descent I accept an understand that the instructor/examiner reserves the right to make
changes or to stop the descent, i t f o l lows that no compensation is payable. If the participant is a mirror. I agree that the
minor has my consent to participate in the canyoning trip/training course.
I also give my consent for ADRENALINE RUSH center and instructors to seek emergency treatment for the minor i f
necessary.
I am presently in god physical and mental health and I certift to be capable of swimming at least 25m.
I have fully informed my s e l f o f t h e contents of this assumption of risk and release by reading it before I signed it on
behelf of my self and my heirs.
I agree to be registered on www.gocanyoning.com platform in order to receive a feedback quality enquiry and to validate
my canyoneer level in compliance with CANYONING international standar.

______________________/ ___________ _______________/ ______________ __________________/ ________

Last Name-First Name of Parrent or Guardion Signature of Parent/Guardian/Date Participant's signature/Date
 Jalan Raya Singaraja – Bedugul
Desa Gitgit, Kecamatan Sukasada, Kabupaten Buleleng
No. Hp : +6285337665069 (Office)

KWITANSI
Trip : ................................................................................
Participant’s : ...................................................... pax
Price : USD ......................x..................... pax
Total : ......................................................

Price : Rp. ...............................................

Total : ......................................................

USD 1 = Rp. 13.000

________ /______/20......

Jalan Raya Singaraja – Bedugul

Desa Gitgit, Kecamatan Sukasada, Kabupaten Buleleng
No. Hp : +6285337665069 (Office)

KWITANSI
Trip : ................................................................................
Participant’s : ...................................................... pax
Price : USD ......................x..................... pax
Total : ......................................................

Price : Rp. ...............................................

Total : ......................................................

USD 1 = Rp. 13.000

________ /______/20......

Jalan Raya Singaraja – Bedugul

Desa Gitgit, Kecamatan Sukasada, Kabupaten Buleleng
No. Hp : +6285337665069 (Office)

KWITANSI
Trip : ................................................................................
Participant’s : ...................................................... pax
Price : USD ......................x..................... pax
Total : ......................................................

Price : Rp. ...............................................

Total : ......................................................

USD 1 = Rp. 13.000

________ /______/20......