Wisconsin Basecamp - Wisconsin Union - University of Wisconsin

							                           Get ready for Basecamp!
        Welcome to the University of Wisconsin – Madison! We’re excited that you’re
considering Wisconsin Basecamp as part of your orientation to the University. Basecamp
provides an opportunity for you to meet your fellow classmates and find out from junior and
senior student leaders what classes are like, campus resources that are available for you,
and what challenges lay ahead while experiencing a great wilderness experience.
        To signup for a trip, you will need to submit a minimum of a $50 deposit (the
complete trip fee is due by one week prior to trip departure) and send in the forms
included in this packet. You can send a check in with these forms or you can call the Mini
Course/Basecamp Office at 608-265-5723 with credit card information (to make sure you
get signed up before your trip is full).
        Please note that additional forms will be mailed to you. These forms will include a
Medical History form and a form to release your academic record/progress and include you
in a study of this program’s effectiveness. Although the enjoyment you’ll have meeting other
students and experiencing the Wisconsin outdoors proves the importance of this experience
to us, providing this information to campus administration helps ensure the sustainability of
this program.
        If you have any questions or concerns prior to the trip, don’t hesitate to contact us.
Enjoy your summer and see you soon!

Jay Ekleberry
jpeklebe@wisc.edu
Wisconsin Basecamp Administrator & Advisor
http://www.wisconsinbasecamp.org

Return forms by mail to
Wisconsin Basecamp
Box 301
800 Langdon St.
Madison, WI 53706

Questions before the trip
Email: info@wisconsinbasecamp.org

Traveling far to come on the trip?
You can combine Basecamp with your SOAR orientation. We recommend that you
complete SOAR and then follow with your Basecamp experience. We have SOAR spots
reserved for people doing this approach and you can stay in campus housing the night
before your trip goes out. Contact us for more information or if you need help with planning.

Emergency contacts during the trip
Jay Ekleberry – 608-262-5759, 608-772-6855 (cell)
Basecamp Office – 608-265-5723
Trip Ground Rules

No guns, knives, or other weapons are allowed on trips (multi-tool/Swiss
Army-type knives are acceptable, but not necessary).

No alcohol, tobacco, or non-prescription drugs are allowed on trips.

No personal electronic devices allowed on the trip. This includes cell
phones, MP3 players, video games, and any other non-medical electronics.
(Trip Leaders will have cell phones in case of emergencies.)

Respectful behavior is expected at all times. Harassment, intimidation,
uncooperative behavior will not be tolerated.

Trip leaders and Basecamp Directors reserve the right to remove a
participant from a trip at any time for failing to comply with these Trip
Ground Rules.

Trip fees are non-refundable.
                                 Wisconsin Basecamp
                                 Participant Information
Which trip would you like to go on? (circle one)
#1 June 14-18    #2 June 15-19      #3 June 21-26      #4 June 23-27 #5 June 28-July 2 #6 July 12-16
#7 July 13-17    #8 July 20-24      #9 July 21-27     #10 July 26-30 #11 Aug 2-6       #12 Aug 3-7

Name _________________________ Birth date ____ / ____ / ____                           M ___ F ___

UW Student ID # __________________________                        T-shirt size: S       M     L    XL

Street Address _______________________________________________________

City/State/Zip Code ______________________ E mail ______________________

Home Phone ________________________                     Cell Phone _____________________

Are your interested in a Basecamp Scholarship Application?                      YES          NO

Emergency Contact (1) __________________________                       Relationship __________

Phone: Home _______________                Work ________________ Cell _____________

Emergency Contact (2) __________________________                       Relationship __________

Phone: Home _______________                Work ________________ Cell _____________

Physician’s Name _______________________________                         Phone ______________
Note: Participants are responsible for any medical expenses incurred. Please
bring a copy of your health insurance card with you on the trip.

Please list any special dietary needs you have (e.g., allergies, vegetarian, etc.):

___________________________________________________________________

Please list any medical information about you that Basecamp leaders should know (i.e.,
conditions which might affect your participation, medications, allergies, etc.):

___________________________________________________________________

By signing below, I certify that the information I have provided above is accurate and complete. I agree to
abide by the trip rules as outlined in this packet and as may be amended by Wisconsin Basecamp
leadership. I grant Wisconsin Basecamp permission to use photos or video of me for publicity purposes
and reprint quotes, essays or other written or spoken materials I produce.

Signature ____________________________________                        Date _________________

Signature of Parent or Guardian (required if participant is under 18)
Signature ____________________________________                        Date _________________
              Agreement for Assumption of Risk, Indemnification, Release,
                       and Consent for Emergency Treatment

My name: (print) __________________________________________________________ Age: _________________
IN CONSIDERATION OF MY VOLUNTARY PARTICIPATION IN THE UW-MADISON Wisconsin Basecamp, I
UNDERSTAND THAT I AM BEING ASKED TO CAREFULLY READ EACH OF THE FOLLOWING PARAGRAPHS. I
UNDERSTAND THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY
CONTACT THE UW-MADISON OFFICE OF RISK MANAGEMENT AT EITHER 262-8925 OR 262-0379.
Assumption of Risks:
I understand that the specific activities of Wisconsin Basecamp, by their very nature, carry with them certain
inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Activities will include canoeing
and camping, and the risks range from: 1) minor injuries such as scratches, minor burns, and cuts, to 2) major
injuries such as broken bones strains, and hypothermia, to 3) catastrophic injuries of drowning, head injuries,
permanent disfigurement, disability, or even death. I understand that the University does not provide any type of
medical coverage and that I must be personally responsible for any injuries I may incur. I understand and appreciate
the risks that are inherent in the above-listed activity. I hereby assert that my participation is voluntary and that I
knowingly assume all such risks.


Signature: ______________________________________ Date: ____________________

Signature of Parent or Guardian (if Participant is under 18*)

Signature: _____________________________________ Date: _____________________
Hold Harmless, Indemnity and Release:
In consideration of permission for me to voluntarily participate in Wisconsin Basecamp during July, 2009, I, for
myself, my heirs, personal representatives or assigns, agree to defend, hold harmless, indemnify and release, the
Board of Regents of the University of Wisconsin System, its officers, employees, agents, and volunteers, from and
against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal
property, or personal injury, or death which may result from my participation in the above-listed activity. This release
includes claims based on the negligence of the Board of Regents of the University of Wisconsin System, and its
officers, employees, agents, and volunteers, but expressly does not include claims based on their intentional
misconduct or gross negligence. I understand that by agreeing to this clause I am releasing claims and
giving up substantial rights, including my right to sue.

Signature: ______________________________________ Date: ____________________

Signature of Parent or Guardian (if Participant is under 18*)

Signature: _____________________________________ Date: _____________________
Consent for Emergency Treatment:
I authorize the University of Wisconsin-Madison and its designated representatives to consent, on my behalf, to any
emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to
be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this
authorization.

Signature: ______________________________________ Date: ____________________

Signature of Parent or Guardian (if Participant is under 18*)

Signature: _____________________________________ Date: _____________________

*If your son, daughter or ward will be under 18 while participating in activities at the University of Wisconsin –
Madison, it is our policy to request your agreement to the above terms, on behalf of your minor son, daughter or
ward.
               ASSUMPTION OF RISK AND WAIVER AGREEMENT - Outfitter
                         (NOTE: This form is NOT needed for Trip #’s 3, 10 & 12)


All adventure activities have inherent risks of physical injury associated with them. The guided canoe trips, canoe
rental and kayak rental offered by Wisconsin River Outings (WRO) are adventure activities and there is risk
associated with being a participant.


Assumption of Risk: I, ___________________________________________________ understand that canoeing and
kayaking exposes me to many hazards and participating in a WRO canoeing, kayaking and camping adventure
entails unavoidable risk of death, personal injury and loss of or damage to property. I choose to participate in this trip
in spite of these risks and hereby assume all risk of injury or loss of life to myself and loss of or damage to property
arising out of my participation in such a trip.

Waiver: In consideration of WRO furnishing services and equipment to enable me to participate in a
canoeing/kayaking trip, I specifically release and forever discharge WRO and its officers, agents and employees from
any and all liability or claims for any injury, illness, death or loss of or damage to property which I may suffer while
participating in this canoeing/kayaking trip.
In signing this document, I fully recognize that if injury, illness, death or damage occurs to me while I am engaged in
this canoeing/kayaking trip, I will have no right to make a claim or file a lawsuit against WRO or its officers, agents or
employees, even if they or any of them negligently cause me injury, illness, death or damage.

I understand that though this may be a guided canoe trip, there will be times when the guide(s) or other participants
may not be in a position to assist, or aid in my rescue in the case of a mishap or the occurrence of a problem.

I understand that WRO recommends that all participants have the physical ability to assist in their own rescue.

I understand that wearing a properly sized, adjusted and buckled personal flotation device (PFD) is critical to my
safety.

I hereby grant WRO the right to take and utilize photographs of me participating in trip related activities for the
purpose of promotion and advertising.

If any portion or provisions of this Assumption of Risk and Waiver Agreement is or are deemed unenforceable by a
Court of Law, the remaining portions and provisions shall remain in full force and effect.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THIS IS A
WAIVER AND A RELEASE OF LIABILITY AND I SIGN IT VOLUNTARILY.



Signature ______________________________________________ Date ___________

____ Signing this waiver for my child or child I’m a guardian of.




Assumption of Risk ~ Boscobel