Participant’s Medical Information
Participant’s Name:
Physician Name:
Physician’s Phone Number:
Overall Physical Condition: Excellent Good Fair Poor
Date of last Tetanus Inoculation or Booster:
Day……….Month……….Year…………
Does the participant have any allergies? Yes No
If yes, list including severity:
Does participant presently take medication? Yes No
If yes, list and indicate if they need assistance:
Other medical concerns (i.e. asthma, emphysema, hay fever, diabetes, epilepsy,
nosebleeds, fainting, heart condition, high blood pressure, etc.):
History of injuries (i.e. broken limbs, tendonitis, bursitis, sprains, dislocation, etc.):
Eyesight: Excellent Good Poor Contact Lenses or Glasses
Please list any physical, emotional or psychological limitations:
Swimming ability: 1 2 3 4 5
Non Swimmer Strong
General Information
Skill levels: Please check appropriate number
Weak Strong
Canoeing 1 2 3 4 5
Hiking 1 2 3 4 5
Swimming 1 2 3 4 5
Camping 1 2 3 4 5
My signature below indicates all information on this medical and general information form is complete and accurate.
Signature of Participant/Parent or Guardian…………………………… Date…………….
Waiver
Participant’s Name Family……………………………………….First…………………………………….
Please read carefully.
* By signing this you recognize and understand the acknowledgement of risk form and you give up all your legal rights to sue for injuries or loss caused during the period that the participant is under the supervision of Kapai Adventures
* We hereby forever release, discharge and hold harmless the instructors, volunteers, directors or any other staff member of Kapai Adventures from any claim, action or damage arising out of the Participant’s activities while participating in a Kapai Adventure program
*We further understand that Kapai Adventures assumes no liability or responsibility for injury or loss to the aforementioned participant’s person or property.
* I /We have read, understood, accept and agree to abide by the policies and guidelines as set forth and acknowledge the risk involved in Kapai Adventures programs. If I have any uncertainty as to the nature of the programs I will request more information from Kapai Adventures head office.
* Please initial each of the above paragraphs to ensure you have read and understand the waiver information.
Signature of Parent/Guardian/Participant…………………………………………………………………
Print Parent/Guardian/Participant…………………………………………………..Date…………………
Photo Waiver / Release
We are asking for permission to use your image or your child’s image in promotional material, and on our website to promote Kapai Adventures. Kapai Adventures can use my image or my child’s image (in photograph, digital, video or electronic form) for and in publications, posters, web-site or other media, without limitation, and I agree not to make any claim for misappropriation of personality, breach of privacy, or other loss or damages against Kapai Adventures in respect thereof.
Please indicate if you agree or disagree with the information above related to Photo Waiver/Release by checking one of the checkboxes:
Agree Disagree
Signature of Parent/Guardian/Participant……………………………………………………..
Print Parent/Guardian/Participant name…………………………………………
Environmental risks and hazards.
These may include such factors as lightning, floods or rock-fall although the more common would be rapid and significant changes in the weather, or unstable or slippery conditions underfoot.
Transportation.
Fireside Adventures trips may involve a significant amount of driving which will be done on highways, secondary roads, and gravel/logging roads. Our drivers follow all road rules including speed limits. There are risks associated with being in a vehicle. Accidents are possible and can even be fatal. We will do our best to minimize the potential for these types of risks by always driving defensively.
Slips and trips.
This is the most common type of accident throughout society and our trips are no exception. We will endeavor to ensure that the consequences of such a slip are not serious but you should be aware that the likelihood of falling over or slipping is likely to be greater than you are used to. Moreover, given the nature of the environment in which these may occur the situation can compound giving rise to a more serious incident. Fireside Adventures has clear obligations and we take these very seriously. However, we will be expecting students to contribute to their own, and each other’s safety by following the instructions leaders will, from time to time, be giving them.
Acknowledgement
I recognize:
- That this trip may require an attitude and approach different from other activities I have been involved with.
- That the nature of the risks may be different to those, which I am familiar with.
- That certain inherent risks remain.
Signature of Participant……………………………………………………………….
Date……………………….
Signature of Parent or Guardian (if applicable)……………………………………..
Date……………………….