Canoe Exploration Registration

Attendee Information

General Information

First Name

Last Name

Date of Birth

Age

Home Address

Medical Information

OHIP Number

Family Doctor

Family Doctor Phone Number

Health Concerns?

Please indicate if you have any health concerns we should be aware of for the purposed of this event.

Allergies or Dietary Restrictions?

If you have any allergies or dietary restrictions, please list them here.

Epipen?

YesNoPlease let us know if you carry an epipen.

Media Consent

I hereby grant A Rocha Canada (ARC) the absolute right and permission to use, re-use and distribute, without financial consideration, photographs, video and/or audio of myself (named above) in any and all media, in perpetuity. I also consent to the use by ARC of my (named above) personal story for use in any media.

YesNo

Gathering Stories

To help us understand the success of our programs, as well as the growth and transformation of our program participants, A Rocha will be gathering participant stories through voice recordings at relevant sharing times (eg. opening and closing circles).

Program participants will be made aware when they are being recorded. These recordings and stories are for internal use only (for gathering data) and will not be publicized in any way, unless Media Consent has been approved above.

The safety and privacy of our participants is vital. If you have questions or concerns, please send us an email at cedar.haven@arocha.ca.

Name (First and Last)

This will act as an electronic signature, confirming
that you have read and agree to the terms above.

Date

Assumption of Risk and Responsibility

In consideration of A Rocha Canada (A Rocha Ontario) accepting my registration for the Canoe Exploration event, I declare that: I am in good health. I have not recently been treated for nor am I aware of any condition that would jeopardize my health or prevent my full participation in the event. If I have any medical condition(s) which may be aggravated by physical exertion, I will make these known to A Rocha Canada representative(s) and will exercise appropriate caution while taking part in the activities

I am a capable swimmer and able to swim at least 100 m without the assistance of a flotation device. If no, pleae check the "no" box below.

YesNo

I understand and accept as my personal responsibility the risks of participating in strenuous canoeing and outdoor activity during this event. If there are risks that I do not understand or am unwilling to accept without clarification, I will discuss these with A Rocha representative(s) either before or during the event. I have the option of refusing to take part in an activity that I feel will expose me to undue risk. Further, I acknowledge that I am responsible for equipment supplied for my use by A Rocha Canada during the event and that any loss or damage of the equipment supplied will be charged to me for repair or replacement.

I agree to abide by the rules/regulations/decisions of the facility operator(s) and A Rocha Canada representatives(s) and staff in matters of safety and group enjoyment. Failure to adhere to this agreement may result in your immediate removal from the event at your expense.

I acknowledge that while at this event, it is my responsibility to obtain appropriate insurance coverage for myself and my property.

In case of an emergency, I authorize the A Rocha Canada representative(s) or designate to administer or obtain appropriate first aid and/or medical treatment should I not be in a condition to make such a decision. Care will be relinquished to responsible family and/or appropriate medical personnel.

Name (First and Last)

This will act as an electronic signature, confirming
that you have read and agree to the terms above.

Date

Liability Waiver

While this event willl be appropriately facilitated by our stafff, there is inherent risk involved. A Rocha Canada and Staff will not be held liable for any injury sustained during program activities.

By submitting your name below, you acknowledge and accept the possible risks, dangers and hazards associated with participation in the activities of this event.

Name (First and Last)

This will act as an electronic signature, confirming
that you have read and agree to the terms above.

Date

Registering another person?

If you are registering more than one person, they must share the same Emergency Contact Information below. Additionally, all persons registered on this form must be paid for together.