Republic of the Philippines Department of Environment and Natural Resources (OFFICE OF THE PROTECTED AREA SUPERINTENDENT ‘Mount Kanla-on Natural Park, Negros Island MOUNTAINEER INFORMATION Name ‘ Age: Sex: Givil Status: Nationality: Home Address Telephone / Fax Email Address ‘Name of School (for Student) School Address Profession/ Occupation Name of Company Company Address Contact Person in case of emergency: Address % Telephone / Fax Is this your first time in the area? Yes. No_ IfNO: How many times you've been in the area? ‘When was your last visit? Area visited: Do you have mountain climbing experience? Yes. No___ If YES: How long? Where? When was the last time? Highest peak climbed so far Check the following Mountaineering Equipment that you have: backpack utility or camping knife full-fly-tent ( 2 season ) head lamp / flashlight sleeping bag hiking shoes ‘ground sleeping mat hiking staff (rod) ‘camping stove & lighter hiking gloves cook set & eating gear first aid kit & insect repellent Rain coat / jacket water bottle /hydro pack = * sleeping sweater/ camp jacket bonnet water collapsible container This ist certify that the above details are othe best of my knowledge and are being provided in relation to my application for ‘mountaineering permit at Mount Kanla-on Natural Pak: that any misrpresetation of information provided shall be aground for nonissuance of my permit: that Lam also duty hound to abide with park laws, rules and regulations. ‘Name and SignatureRepublic of the Philippines Department of Environment and Natural Resources OFFICE OF THE PROTECTED AREA SUPERINTENDENT Mount Kanla-on Natural Park, Negros Island 1 » of legal age, » and a resident of , hereby renounce or waive any and all claims I may have against and release from all liability and agree not to sue the Department of Environment and Natural Resources, the Office of the Protected Area Superintendent and/or any of its authorized representatives, the Protected Area Management board of Mount Kanla-on Natural Park for any untoward incident(s) / accident(s) that may result to my injury, death, and property damage or loss sustained by me as a consequence of circumstances beyond human control, or force majeure in nature, or otherwise directly or indirectly due to negligence of recklessness on the part of the expedition/ climbing party, arising out of my participation in mountaineering activity at Mount Kanla-on Natural Park Further, the PAMB, DENR, PASu and/ or any of their authorized representatives, are not to be held liable/ responsible for any circumstances brought about by natural agents that may directly or indirectly affect, delay, or cause the abortion/ cancellation of a duly approved and already processed application. Tam aware that mountaineering in Mount Kanla-on Natural Park has extreme dangers and risks especially that the area is an active volcano. Furthermore, I was property oriented on the terms and conditions of the mountaineering permit and I am taking full responsibility and willingly accept all the risks involved in my trek/ climb at the summit of the active volcano of mount Kanla-on Natural Park. 1 am physically fit to undergo this seriously strenuous endeavour. ‘Name and Signature Subscribed and sworm to before me this day of » Philippines. Affiant exhibit to me his/her passport or CTC No. sued on, at : Notary Public Doc. No. Page. No. Book No. Series No.