Forms

Firefly Adventures

Waiver of Liability Agreement

Name: __________________________________________Age:___________

Address:_____________________________City:                             Province/State:              Postal/Zipcode_________ Date:                                 If under 18, guardian’s signature :_________________________________

Course or trip: _______________________

SAFETY STANDARDS AND RULES

I, the above named person, being above the age of eighteen, or the legal guardian of the above named person who is under eighteen, in consideration of Firefly Adventures hereinafter referred to as Firefly, will abide by the following safety standards and rules for any courses, clinics or trips run by Firefly or its agents.

1.        Personal Floatation Devices (life jackets) will be worn and fastened correctly while in any water craft or while near the water.

2.         All instructions pertaining to safety will be complied with immediately.

3.        Appropriate footwear will be worn while portaging, running rapids, lining or tracking canoes, participating in rescue activities or any other circumstances required by the leader.

4.         No rapid will be run by any participant if any instructor or leader deems it to be too difficult for the participant.

5.        Instructors or leaders may clearly lay out safety standards or rules for specific activities not contained in this list. All must be adhered to.

6.         All rapid running is voluntary. You will not be forced to run any rapids you do not want to.

7.        Rescue activities are all voluntary. Do not take part in specific activities you are not comfortable with.

I have read this section and initial to show that I understand and agree. _________

ACKNOWLEDGMENT OF RISKS

I understand and acknowledge that the activity I am about to voluntarily engage in as a participant and/or volunteer bears certain known risks and unanticipated risks which could result in injury, death, illness, disease, or damage to myself, to my property, to other participants, to spectators, or to other third parties.  Among these risks are the following:

1.        The nature of the activity itself,

2.         Acts or omissions by Firefly, its agents or employees, and or other persons,

3.         Latent or apparent defects in equipment supplied by Firefly or other persons,

4.        Use or operation, by myself or others of equipment supplied by Firefly or other persons,

5.        Acts of other participants in this activity, employees or agents of Firefly or other persons,

6.        Weather conditions,

7.        Contact with plants or animals,

8.        My own physical condition, or my own acts or omissions,

9.       Conditions of roads, trails, waterways or terrain, and accidents connected with their use.

I understand and acknowledge that the above list is not complete or exhaustive, and that other risks known, or unknown, identified or unidentified, anticipated or unanticipated may also result in injury, death, illness, disease, or damage to myself, to my property, to other participants, to spectators, or to other third parties. I expressly accept these risks and those not specifically listed above as well.

I have read this section and initial to show that I understand and agree. ________

ACCEPTANCE OF RISK AND RESPONSIBILITY

I am aware that this activity entails risks or injury to myself and risk or injury to other participants, spectators or other third parties as a result of my participation. I expressly agree, covenant and promise to accept and assume responsibility and risk for injury, death, illness, disease, or damage to other participants, to spectators, or to other third parties and their property arising from my participation in this activity. My participation in this activity is purely voluntary; no one is forcing me to participate, and I elect to participate in spite of the risks.

I have read this section and initial to show that I understand and agree. ________

RELEASE

Having read this document, I hereby voluntarily release and forever discharge Firefly, its agents or employees and all other persons or entities from any liability (including negligence), or claims, which are related to, arise out of, or are in any way connected with my participation in this activity. I also waive claim against Firefly, its agents or employees and all other persons or entities for any delays howsoever caused, arising out of, or in any way connected with the participation in this activity.

I have read this section and initial to show that I understand and agree. _______

PARTICIPANT INSURANCE BENEFITS AND REPRESENTATION

OF PHYSICAL  CONDITION

I understand and acknowledge that no major medical insurance benefits will be provided to me during this activity. I certify that I have sufficient health and accident insurance to cover any bodily injury I may incur while participating in this activity. If I have no such insurance, I certify that I am capable of personally paying for all such expenses.

I am in good health and able to participate in this activity. All medical information has been fully disclosed on the medical information form.

I have read this section and initial to show that I understand and agree. ________

ENTIRE AGREEMENT

I understand that this is the entire Agreement between myself and Firefly, its agents or employees, and that it cannot be modified or changed in any way by the representations or statements of any employee or agent of Firefly, or by me.

My signature below indicates that I have read this entire document, understand it completely, and agree to be bound by its terms.

DATE:­­ ­___________

SIGNATURE OF PARTICIPANT: ________________________________

SIGNATURE OF WITNESS: ­­­­­­­­­­­­­­­____________________________________

SIGNATURE OF PARENT OR GUARDIAN (if under 18): ­­______________________________

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Firefly Adventures

 Registration, Medical Information & Consent Form

To ensure a safe experience, accurate and complete information is essential. For single applicants, use one line only. For families, use multiple lines.

Date(s) of activity: ________________________________________

First Name                    Last Name                  Age              Date of Birth

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Full Mailing Address

______________________________________________________________

Home Phone # _________________________

Emergency Contact Information   – In the event of an emergency, please provide contact information for a relative or close friend.

Name ___________________ City _______________ Phone # __________

Please give a brief summary of past canoeing and camping experiences/certifications. __________________________________________________________________________________________________________________________________________________________________________________________

Do you have health insurance from home or travel? Yes ___ No ____

Please list all medications you are taking as well as any physical conditions (knees, back) which may require attention during this activity. ____________________________________________________________________________________________________________________________

During the activity, administration of over-the-counter medications may be necessary.  These may include: Acetaminophen, Ibuprofen, Laxatives, Anti diarrhetics, Anti allergic medications (Benadryl), Hydrocortisone cream, Polysporin and others.

I attest that I and those above are physically capable of this activity and give permission for the administration of over the counter medications if necessary.

This personal information is collected in accordance with the Municipal Freedom of Information and Protection of Privacy Act.

Name print ______________________ Signature _____________________

Date _____________