200 Main Street
Winnipeg, Manitoba
R3C 4M2
Ph: (204) 925-5681
Fax: (204) 925-5703
[email protected]
U 18 Trip Permission Form
Medical Summary, Code of Conduct, & Liability Waiver
Name of Event: ___________________________
From date: __________ to:__________
I/We hereby give permission for my child _______________________________________________ to attend the
event named above, for the dates specified, sponsored and organized by the Manitoba Paddling Association.
While participating in this event, I understand my child must abide by the Manitoba Paddling Association Code of
Conduct, which has been provided to me with this form, or may be sent home at my expense. I also realize that my
child must bring his/her own spending money. I/We fully understand that while all activities will be supervised, the
coaches, chaperons, and Manitoba Paddling Association can not be held responsible for an athlete’s own negligence
or failure to use good judgment.
I send my child on this trip knowing that Sprint Racing Canoeing and Kayaking involves certain risks and that
precautions will be taken to minimize these risks. Although the Manitoba Paddling Association insures all
participants for medical emergencies, I am aware that I am responsible for medical bills in excess of the insurance
and that Blue Cross/other travel health insurance is recommended for international trips. My child’s medical and
insurance information is as follows (please attach additional page if health history is complex or lengthy):
Significant Health Problems: ____________________________________________________________
Medications: _________________________________________________________________________
Allergies: ___________________________________________________________________________
MB Health & PHIN numbers: __________________________________________________________
Additional Insurance Carrier & Policy Number:____________________________________________
I hereby give authority for the Provincial Coach Jerome Seremak or his designate to seek medical care for
my child in case of an emergency. I hereby waive and release the Manitoba Paddling Association, its directors,
officers, employees, agents, representatives, successors and assigns from and against all claims, actions, demands,
costs and expense in respect to death, injury, loss or damage to my person or property, howsoever caused,
contributed to or occasioned by the negligence of the Corporation, its directors, officers, employees, agents,
representatives, successors and assigns. This Waiver and Release shall be binding upon myself, my heirs, executors
and administrators.
I, being a parent of legal guardian of _________________________, hereby agree that
(NAME OF PARTICIPANT)
the foregoing permission form, commitment to abide by the Manitoba Paddling Association’s Code of
Conduct, and waiver and release shall be binding upon my child.
Dated this____________ day of
______________________________
WITNESS
, 20
.
______________________________
PARENT’S SIGNATURE
_____________
DATE
Note: To confirm this information, I can be reached at the following numbers (work, cell, home – for 24 hours/day):
1) ____________________________
2) ____________________________
3) ____________________________
CODE OF CONDUCT FOR MPA EVENTS
- guidelines for disciplinary action
APPLIES TO ATHLETES, MASTERS ATHLETES, COACHES, MANAGERS & CHAPERONES
INFRACTION
MINOR
EXAMPLE
Poor personal hygiene: dirty, torn, messy or
smelly clothes or person
JUDGE
Coach OR
Manager
CONSEQUENCES
(NON-PROBATION
ATHLETES)
1.
verbal or written apology
2.
If possible, address problem (i.e.
clean up if issue is cleanliness)
3.
Other potential consequences:
-pushups
-hops
-early curfew
-grounding
-confinement to AV
-suspension from team
activities
Late for team meetings, events, departures
Lack of courtesy or respect for fellow team
mates, competitors, coaches, managers,
volunteers or mission staff; disrespectful,
abusive, offensive, racist or sexist comments or
behavior
Lack of cleanliness in room, dining or at races;
includes littering an failure to clean up one’s
room or in dining room
CONSEQUENCES
(PROBATION
ATHLETES)
As for non-probation
athletes
* may be appealed to coach/ manager or
to athlete rep
Negative or disrespectful comments to media
Any behavior which unintentionally results in
damage to property or harm to another person
Visible possession or use of tobacco by nonmasters athletes > 18 (unless sanctioned) OR
use of tobacco by other persons officially
associated with MPA in close proximity to
athletes.
MAJOR
> 5 minor infractions in a non-probation
athlete or > 3 minor infractions in a probation
status athlete
1.
Immediate probationary status for a
period to be determined by the
MPA Board
Failure to perform consequences for minor
infractions in a probation status athlete.
2.
Written & Verbal apology for
behavior
Possession or use of alcohol by non-masters
athletes unless sanctioned by coach and
manager (use of alcohol in such circumstances
by athletes < 18 will be treated as a minor
infraction)
3.
Reparations for any damages done
4.
volunteer work as assigned
5.
Abuse of alcohol resulting in loud,
belligerent or unseemly behavior, or
the inability to carry out official
duties
Balance all accounts immediately
and pay for any subsequent events
fully prior to departure.
6.
If severe infraction, consequences
as for probation status athlete may
be considered.
Use of any illegal substances
7.
For coach/ manager/chaperone,
consequences to be determined by
the MPA.
Positive drug test for banned substances
Any criminal activities such as vandalism, theft
Any behavior which intentionally results in
damage to property or harm to another person
BOTH Coach
AND
Manager
1.
Immediate suspension
from MPA practices
and events for a period to
determined by the MPA
Board
2.
Immediate loss of
carding status
3.
If occurring while out of
town, immediate return
home at own expense
(provided safe return can
be arranged for minors)
4.
Reparations (if
applicable) for any
damages done or travel
home
5.
Once suspension expired,
full one-year period of
probation.