Rivers to Ridges Participant Form
Participant Information
Name:
Address:
Phone:
E-mail:
Gender
Female
Male
Age:
Other
Birth date:
Guardian, Emergency, & Medication Information
Parent/Guardian Information
Emergency Contact
(if under the age of 18)
Name:
Home Address:
Name:
Home Address:
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
Work Phone:
Relationship:
Family Doctor:
Please provide any additional important contact information
Yes
Allergies
No
Allergy:
Anaphylactic?
Yes
No
Does your child have any medical or behavioural issues
our staff should be aware of?
________________________________________________________
________________________________________________________
________________________________________________________
Medication(s)
(1)_________________________________
(2)_________________________________
If yes, does child carry
epipen?
Please Note: Staff WILL NOT administer medication.
Please check which program that participant will be involved in:
After-School Pilot Program
Weekend Intensive Workshop
Other _____________________________________________________
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•
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If the participant will not be in attendance as expected, please call or
leave a message for Emily at 867-334-8955
Appropriate clothing for outdoor activities will be necessary for the
weather; this includes good boots, mitts/gloves, hat, and jackets.
We request NO electronics (cell phones, cameras, IPods/Pads, Tablets, etc)
be used during the sessions, except to take special photographs.
CONSENT TO PARTICIPATE
Waiver of Liability
I, the undersigned understand and acknowledge my child’s participation in the
________________________ (name of program). This agreement releases Rivers to
Ridges from all liability relating to injuries that may occur between ______________
___ (date of program). By signing this agreement, I agree to hold Rivers to Ridges
and their subcontractors entirely free from any liability, including financial
responsibility for injuries incurred, regardless of whether injuries are caused by
negligence.
I also acknowledge the risks involved in outdoor play and exploration. These
include but are not limited to lifting heavy logs, rocks and other found objects,
running quickly through near sharp objects (broken braches etc), walking
barefoot through the forest, falling or tripping over forest objects, encounters with
bears, domestic dogs, foxes or other wildlife, getting stung or pricked by plants
(i.e. stinging nettle or wild rose) and others that may not be mentioned. I swear
that I, or my child, are participating voluntarily, and that all risks have been made
clear to me. Additionally, I do not have any conditions that will increase my
likelihood of experiencing injuries while engaging in this activity.
By signing below I forfeit all right to bring a suit against Rivers to Ridges for any
reason. In return, I will receive skills and I will also make every effort to obey safety
precautions as listed in writing and as explained to me verbally. I will ask for
clarification when needed.
I, _______________________, fully understand and agree to the above terms.
Permission is hereby granted to administer First Aid treatment and/or
access medical attention that may be required.
Name of participant: _________________________________________________________
_________________________________________
Signature of Parent/Guardian
______________________________
Date
Photo Release Form
Our staff may photograph programs and special events to catch participants in
action. Please let us know if you object to photographs of you or your child being
taken.
I grant to Rivers to Ridges, its representatives and employees, the right to take
photographs of_____________________________________ (print name of participant)
in connection with the above-identified subject. I authorize Rivers to Ridges, its
assigns and transferees to copyright, use and publish the same in print and/or
electronically.
I agree that Rivers to Ridges may use such photographs of my child with or
without my name and for any lawful purpose, including for such purposes as
publicity, illustration, social media and other forms of advertising and web content
to be distributed.
I have read and understand the above:
______________________________________________________________________
Participant Name
_____________________
Date
______________________________________________
Signature of parent/legal guardian