YWCA Edmonton – YoWoChAs Outdoor Education Centre

Adult Participant Information Form - Outdoor Education Camp

For Adult Particpants 18 Years or Older

School/Group: ________________________Camp Dates: ____________________

Camper Information

Name: ______________________________________________________________

Address: ____________________________________________________________

City: ________________________ Postal Code: _________________

Phone Number: __________________Alberta Health Care #____________________

Birthdate: Y____ M _____ D _____ Age ______ Gender________________

Height ________ Weight ________ Swimming Ability/Level ____________________

Do you have additional health coverage? Yes    No

If yes, provider's name and plan number ____________________________________

Emergency Contacts

Contact One                                 Contact Two

Name               _____________________                  ______________________

Day Phone      _____________________                  ______________________

Eve Phone      _____________________                  ______________________

Relationship    _____________________                 ______________________

Family Doctor _____________________ Office Phone ___________________

Medical Information

Consent

I, the undersigned participant, understand the above information is collected in accordance with privacy legislation. In signing this form, I give permission for the above information to be used for the sole purpose of providing medical care and support for the duration of the camp programme.

I acknowledge that in the event of an emergency, treatment may be provided to myself by a physician selected by the YWCA of Edmonton and that I will be financially responsible for any costs associated with such treatment and services, such as ambulance service.

I understand that it is my responsibility, to inform the YWCA of Edmonton of any medical or health concerns that may affect my participation in camp programmes and related events and activities.

Date Signed:           __________________________

Participant Name:   _________________________________________________________________

                             Print Name                                     Signature

Please ensure that NOTIFICATION & UNDERSTANDING OF RISKS FORM is also complete

YWCA Edmonton - YoWoChAs Outdoor Education Centre

NOTIFICATION & UNDERSTANDING OF RISKS FORM

For Adult Particpants 18 Years or Older

Note: If this form is not complete, you will not be permitted to participate in camp activities .

I, the undersigned participant, am aware that participation in YWCA YoWoChAs Outdoor Education Centre programmes (the "Programme") involves inherent risks, dangers and hazards, including, but not limited to:

•  all manner of injury or loss, including potentially serious or life-threatening injury and death, resulting from the use of equipment, materials or facilities related to the Programme and it's events and activities;

•  all manner of injury or loss, including potentially serious or life-threatening injury and death, resulting from forces of nature, accident, hazards of participating in outdoor activities and sports including activities and sports taking place on or near water, illness, allergic reactions and all other manner of injury related to the Programme and its events and activities;

•  all manner of injury or loss, including potentially serious or life-threatening injury and death, resulting from the actions or negligence of other participants in the Programme and related events and activities; or

•  additional risks, injury or loss, including but not restricted to unforeseen additional risks, injury or loss arising out of the Programme and related events and activities.

I, the undersigned participant, am aware of these risks, dangers and hazards and the possibility of injury, death, property damage, property loss or other loss or expense resulting to myself.

In consideration of being allowed to use the equipment, materials and facilities of the YWCA Edmonton and being allowed to participate in any way in the Programme and related events and activities at the YWCA Edmonton, we the undersigned participant, hereby agree as follows:

•  TO ABIDE BY the rules and regulations including directions and instructions from YWCA staff and in the event that there is a failure to do so, I agree that I may be excluded from further participation in the Programme and that I may be removed from the Programme;

•  That this Agreement will be effective and binding upon myself, my heirs, next of kin, executors, administrators and assigns in the event of myself or my death.

I , the undersigned participant, hereby acknowledge that I have read the foregoing.

I acknowledge that I understand the content, importance and meaning of the Notification and Understanding of Risks form and hereby do approve and consent to the above.

Date Signed:           __________________________

Participant Name:   _________________________________________________

                             Print Name                                            Signature