Name
*
First Name
Last Name
Weight and Waist Size
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Email
*
Additional Family Member #1
First Name
Last Name
Weight and Waist Size
Additional Family Member #2
First Name
Last Name
Weight and Waist Size
Additional Family Member #3
First Name
Last Name
Weight and Waist Size
Additional Family Member #4
First Name
Last Name
Weight and Waist Size
Additional Family Member #5
First Name
Last Name
Weight and Waist Size
IN CASE OF EMERGENCY NOTIFY:
*
Cell Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
IN CASE OF MEDICAL EMERGENCY CONTACT FAMILY PHYSICIAN:
*
Phone
*
(###)
###
####
Parents/Guardians please describe any conditions, allergies, or activity or food restrictions that you feel are necessary to advise outing organizers for the saftey or well-being of your child.
Medical Insurance ID Number, Insurance Company, and Group Number:
*
Release of Liability & Participant Agreement: I acknowledge that certain hazards and dangers are inherent in outdoor activities and programs. I hereby release Canoe Creation, the owners of the properties on which activities are conducted and the chaperones or organizers of the Canoe Creation outing from any claims for personal injury or property damage arising from the participation in this Canoe Creation outing. The participant herein described has permission to engage in all outing activities except those noted. I understand that an injury sustained by the participant while participating in Canoe Creation outings will not be covered by insurance provided by the organizers, Canoe Creation or the owners of the locations on which they visit in the course of the outing. This agreement is made in Christian trust and in good faith that the organizers, chaperones, and members of Canoe Creation ministry team will take all precautions in safety. I am also trusting that Canoe Creation will respect the wishes of the parents (or guardians) of the participants, and will put the well-being of all of the participants as the highest priority. I will also permit use of photographs of participant for promotional purposes.
*
By typing your name in the box below, you are providing your digital signature and legal agreement to the statement above.
First Name
Last Name
Additional Adult (if applicable)
By typing your name in the box below, you are providing your digital signature and legal agreement to the statement above.
First Name
Last Name
ALL Additional Family Members Participating
By typing the name/s in the box below, you are providing your digital signature and legal agreement to the statement above.
Date
MM
DD
YYYY
I (the Participant/Parent/Guardian) understand and agree to abide by any restrictions placed on my participation in Canoe Creation activities and agree to abide by rules set out by the organizers of the Canoe Creation outing. (Family group leaders agree to enforce agreement for all members).
*
By typing your name in the box below, you are providing your digital signature and legal agreement to the statement above.
First Name
Last Name
Additional Adult (if applicable)
By typing your name in the box below, you are providing your digital signature and legal agreement to the statement above.
First Name
Last Name
ALL Additional Family Members Participating
By typing the name/s in the box below, you are providing your digital signature and legal agreement to the statement above.
Date
MM
DD
YYYY
I authorize the chaperones or Canoe Creation to dispense the following for me or my participating child if needed during the course of the outing (please check all that apply):
Other:
The Participant/s (Parents check all that apply & add details in box below if needed):
Check any conditions that the participant is known to have:
Please list any additional details or any other medical conditions we should be aware of:
