Chaperone Self Registration

Submitted

Please note this project is closed for online Chaperone Registration.

Project Information

Project Name

Group Name

Chaperone Information

First Name	Last Name
Street Address	City
Province	Postal Code
Phone	Email
Gender MaleFemaleOther	Date of Birth

Risk & Waiver

By clicking here I agree that I have read and understand this Assumption of Risk, Waiver of Liability and Indemnity Agreement. I am aware that by submitting this document, I am waiving certain legal rights, including the right to sue or claim compensation from the Releasees following an accident and I voluntarily agree to its terms.I understand that the Experiences Canada and Her Majesty are relying on my full assumption of risk, release and waiver of all claims when accepting my participation in the Exchange Program. Waiver Form

ACKNOWLEDGEMENT AND ACCEPTANCE OF RISK AND RESPONSIBILITY

I, being a Group Organizer/Chaperone, understand and acknowledge that I have been offered an opportunity to take part in Experiences Canada Youth Exchanges Canada (the "Exchange Program"), which is funded by Experiences Canada (hereinafter "Experiences Canada") and her Majesty the Queen in Right of Canada as represented by the Minister of Canadian Heritage ("hereinafter "Her Majesty"). I acknowledge that I have read a description of the Exchange Program and its objectives, which are aimed at enhancing the youth participants' knowledge of Canadian history, heritage and community and the development of second language skills and community engagement. I further understand that the Exchange Program has among its learning objectives the promotion of physical activity and the development of environmental responsibility. I understand all the inherent and potential risks of the activities related to the Exchange Program and that participation in the Exchange Program involves travel, the use of private accommodations and other facilities where Exchange Program activities take place. I acknowledge that I have been informed of my right to obtain as much information about the Exchange Program as I feel is necessary.  In signing this Agreement, I acknowledge that I am not relying on any oral or written statements that may have been made by Experiences Canada to induce me to participate in the Exchange Program, other than those set out in this Agreement. I acknowledge that in all circumstances, the liability of Experiences Canada and Her Majesty in relation to the Exchange Program shall be determined in accordance with the terms of this Agreement.  Risks  I understand that my participation in the Exchange Program involves a risk of serious and/or permanent injury or death and damage to or loss of property. The risks include such events as slips, trips, falls, collisions, equipment failure and illness. I understand and acknowledge that I may suffer serious and/or permanent injury or damage to or loss of property, resulting directly or indirectly from my own negligence, failure to follow directions, misadventure or unavoidable or unintentional accident. I also understand and acknowledge that all of the potential risks cannot be listed in this Agreement.  I understand that the Exchange Program may involve other risks including restricted availability of immediate medical assistance, the conduct of other Group Organizers/Chaperones whether or not such conduct is negligent or reckless; and the contraction of a contagious illness or communicable disease. I understand that my participation in the Exchange Program may negatively affect my future ability to work or engage in social and recreational activities.  Unforeseen Events  I understand that Experiences Canada, sometimes in partnership with the organizers, will be facilitating some of the Exchange Program activities. I understand that despite all reasonable precautions being taken to provide proper organization, circumstances may arise which are not foreseeable or which are beyond their/its control. I understand and acknowledge that Experiences Canada is not responsible for any damages caused for the delay or failure to perform or complete any activities or to provide any transportation or accommodation when such delay or failure is due to fires, strikes, floods, acts of God, war, terrorist activities, lawful acts of public authorities or delays or defaults caused by common carriers, which cannot reasonably be foreseen or provided against.  Responsibility  As a Group Organizer/Chaperone, I further understand that I have full responsibility for all participants under my supervision. I will participate in all activities while I am hosting and being hosted. I will also ensure that everyone involved in the Exchange Program abides by Experiences Canada's Code of Conduct.  I hereby provide my full and voluntary informed consent to my participation in the Exchange Program. I freely and fully assume all risks, including but not limited to any serious and/or permanent injury or death and damage to or loss of property associated with participation in the Exchange Program and all responsibilities outlined above associated with my participation in the Exchange Program.  PARTICIPANT'S FITNESS  To the best of my knowledge, I do not have any contagious illnesses and am physically, mentally and emotionally capable of participating in all of the activities of the Exchange Program. I am not aware of any reason, health related or otherwise why I would not be capable of participating in the Exchange Program activities.  If, to my knowledge, I have any significant change in my health condition prior to the Exchange Program start date, or during the Exchange Program, I will inform Experiences Canada immediately. I acknowledge that my failure to do so may result in my inability to participate or remain in the Exchange Program.  In exchange for Experiences Canada allowing my participation in the Exchange Program, I hereby agree: 1. to waive any and all liability of Experiences Canada and/or Her Majesty, including vicarious liability, except incircumstances of gross negligence or wilful misconduct; 2. not to commence or participate in any type of claim or lawsuit against Experiences Canada and/or Her Majesty,except in circumstances of gross negligence or wilful misconduct; 3. to release, indemnify, hold harmless and forever discharge Experiences Canada and/or Her Majesty for any losses,damage, injury or expenses related to the my participation in the Exchange Program, except incircumstances of gross negligence or wilful misconduct.  “Gross Negligence or Wilful Misconduct” means any act, omission or failure to act (whether sole, joint or concurrent) by a person that was intended to cause, or was in reckless disregard of, or wanton indifference to, the harmful consequences to the safety of another person which the person acting or failing to act knew (or should have known) would result from such act, omission or failure to act.     EXCLUSIVE JURISDICTION  I agree that any dispute relating to my participation in the Exchange Program shall be litigated, if at all, in the Superior Court of Ontario located in Ottawa, Ontario. The applicable law to be applied to any dispute shall be the law of the Province of Ontario.  MISCELLANEOUS PROVISIONS  Experiences Canada includes its employees, directors, officers, designates, representatives, agents, successors and assigns. This Agreement enures to the benefit of and binds the parties and their respective heirs, executors, administrators and representatives, successors and assigns.  This Agreement constitutes the entire Agreement. If any provision of this Agreement is held by a court to be unenforceable, then such provision will be modified to reflect the parties' intention. All remaining provisions of this Agreement shall remain in full force and effect as drafted.  By my signature I indicate that I have read, understand and agree with all of the terms of this Assumption of Risk, Waiver of Liability and Indemnity Agreement. I am aware that by signing this document, I am waiving certain legal rights, including the right to sue or claim compensation from the Releasees following an accident and I voluntarily agree to its terms.  I understand that the Experiences Canada and Her Majesty are relying on my full assumption of risk, release and waiver of all claims when accepting my participation in the Exchange Program.

Consent

By clicking here I agree that I freely give my consent to the collection and use of personal information as set out below Consent

I hereby give my consent for Experiences Canada to collect the personal information required for participation in the Experiences Canada Youth Exchanges Canada Program.  I understand that this personal information is required for the purposes of program delivery and that it will only be used by Experiences Canada or disclosed to select third parties who are acting as suppliers, service providers or who provide funds to Experiences Canada and who have agreed to protect the personal information supplied by Experiences Canada.

Photo Consent

I understand that I may have the opportunity to express myself verbally or in written form, appear in photographs and/or video recordings at any point during the EXPERIENCES CANADA Exchange Program, individually or as part of the group.

Please click YES or NO

YES, I give Experiences Canada, its funders and associated partners, permission to release and/or publish the statements, photographs and/or video recordings.NO, I do not give Experiences Canada, its funders and associated partners, permission to release and/or publish the statements, photographs and/or video recordings.

Contact Information