PINCH-O-CROW CREEKERS CLUB
ACKNOWLEDGEMENT OF RISK AND
CONSENT OF PARENT/GUARDIAN
for youth under the age of 18
Participant’s Name: ________________________________________
The Pinch-o-Crow Creekers Club, the Alberta Whitewater Association, Paddle Alberta and its members, leaders/instructors/coaches, directors, agents, employees, volunteers and representatives (hereinafter referred to as the “Club”) make available paddling programs for the benefit of the participant. These programs contain risks, dangers and hazards for all participants.
Please read the contents of this Consent and Acknowledgement of Risk form. Clarify any questions or concerns with the Club BEFORE signing it. If this form is not signed and returned to the Club, your child/ward WILL NOT BE ALLOWED TO ATTEND.
DESCRIPTION OF RISKS
I acknowledge that I am aware of the possible RISKS, DANGERS AND HAZARDS associated with the programs, outdoor adventures and activities for kayaking. canoeing, paddleboarding, rafting (hereafter referred as Paddling Sports) either in a pool or outdoors in lakes, rivers or sea, and travel in vehicles including THE POSSIBLE RISK OF SEVERE OR FATAL INJURY TO MY CHILD/WARD OR OTHERS. These risks, dangers and hazards include, but are not limited to:
♦ The risk of DROWNING or near drowning including but not limited to: falling out of the kayak/canoe/paddleboard/ raft into the water, underwater entrapment by a water feature, equipment entanglement or being knocked unconscious in the water;
♦ Injuries resulting from your body hitting the canoe/kayak/paddleboard/raft, paddle, water surface, pool surface, shoreline embankments, underwater features or being hit by another boat or paddler
♦ Extremes of cold and hot weather and temperature which may result in hypothermia, hyperthermia, sunstroke, sunburns or heat exhaustion
♦ Prolonged or sudden exposure to cold water which may result in hypothermia or cardiac arrest
♦ Hazards related to windstorms, thunderstorms, lightning, hailstorms, or snowfall
♦ Hazards related to travel in and on lakes, rivers or seas
♦ Hazards related to poles, wires, strings, gates and/or crossbars used to hang slalom courses or mark downriver courses that may entangle or snare a person on the water
♦ Remote locations in mountain terrain, river valleys and canyons with poor communications and inability to get rescue or medical assistance quickly or easily
♦ Unfamiliar country and wilderness areas where the participant may be separated from the rest of the party, become lost, get off course or become stranded.
♦ Medical problems arising before, during or after the trip
♦ Terrain where a slip, trip or fall may cause injury or death
♦ Other injuries (e.g., blisters, sprains, strains, dislocations, acute or overuse injuries);
♦ Additional risks associated with travel to and from locations including transport by public or private motor vehicle, helicopter and fixedwing aircraft that may result in a vehicle accident
♦ Failure to follow directions from instructors or those in charge of outdoor trips, including those specifying
a) staying with the group at all times unless those in charge are consulted and provide consent;
b) wearing an approved personal flotation device (PFD) when on and around water and a helmet on rivers;
c) safe use of tools and other equipment where required
♦ Illness related to poor personal hygiene or any illness resulting from contagious diseases
♦ Illness related to ingesting unpure food or liquids
♦ Allergic reactions to natural substances in the environment (i.e. but not limited to poison plants, insect bites or stings, poison venom)
♦ Allergic reactions to substances in food items
♦ Injuries related to encounters with animals and plants in the environment;
♦ Injuries related to equipment (poor fit, improper adjustment, malfunction, or becoming tangled)
♦ Injuries related to lifting, carrying, walking with, or putting down the craft and/or packs;
♦ Other risks normally associated with participation in the activity and environment.
♦ Loss of or damage to my boat, paddle, gear and other equipment before, during or after the activity
CONSENT AND ACKNOWLEDGEMENT OF RISK
1. I acknowledge it is my duty and my right to obtain as much information as I require about this program or activity and associated risks and hazards, including information beyond that provided to me by the Club.
2. I freely and voluntarily assume the risks/hazards inherent in the program/activity and understand and acknowledge that my child/ward may suffer personal and potentially serious injury arising from his/her participation.
3. I acknowledge that the Club has the right to refuse to allow my child/ward to participate in any activity if, in the Club’ opinion, the participant is not adequately fit, not properly equipped, insufficiently skilled, suffering an illness or otherwise not ready to participate safely.
4. My child/ward has been informed that he/she is to abide by the rules and regulations, including directions and instructions from the Club and/or service providers, administrators, instructors/coaches, and supervisors over all phases of the program/activity.
5. My child/ward has read and been informed that he/she is to abide by the Code of Conduct and rules.
6. In the event my child/ward fails to abide by the rules and regulations or Code of Conduct or rules, disciplinary action may require his/her exclusion from further participation, or that I be contacted to have him/her picked up, unless I have specified other transport arrangements. I will be responsible for any related costs associated.
7. I acknowledge that it is my duty to advise the Club of any medical/health concerns (e.g., illnesses, medical, physical, emotional, learning, and/or behavioral conditions) of my child/ward that may affect his/her participation.
8. I acknowledge that the Club may choose to cancel the activity if conditions are deemed unsafe (e.g., weather, health advisory). I accept that the Club will not be liable for any costs associated with such a cancellation.
9. I acknowledge that the Club may secure transport to emergency medical services as they deem necessary for my child/ward's immediate health and safety, and that I shall be financially responsible for such services
10. Based on my understanding, acknowledgement, and consents as described herein, I agree that my child/ward has my permission to participate throughout this calendar year.
Name of Participant ________________________________ Date of Birth ______________________________
Parent/Guardian Name______________________________ Name of Witness ___________________________
Signature: _______________________________________ Signature of Witness ________________________
Signed this _________day of ________20_____
Phone Number: ____________________ E-Mail Address ______________________________________
Address _______________________________ City _______________________ Postal Code ____________
Image Release
I grant permission to the Associations the right to use, without payment of any fee or charge and without limitation on time or frequency, for nonprofit, educational, promotional or publicity purposes only, any photographs, video footage, audiotape or digital images of my child/ward.
Yes No
My child/ward’s identity: May be revealed May not be revealed
Parent/Guardian Name __________________________ Date: _____________________________
Signature ______________________________________