Atlantic Division CanoeKayak Canada (ADCKC)
PO Box 295, Station Main
Dartmouth NS
(902) 466-9925 www.adckc.ca
Mobile Kayak Program
“Lightnings’ strike” 2015
Participant Information:
Participant Name:
Phone Number:
Address:
Guardian Name:
Email:
Emergency Contact
Name and number:
Participant DOB:
Participant
Allergies:
Consent to Release Contact, Date of Birth Information
I understand that the Atlantic Division, Canadian Canoe Association (ADCKC) may
contact me to conduct a “post” Mobile Kayak program survey to help improve the
program and collect my input on future programming.
I also understand that the above information will be stored in the ADCKC database
(Pad Trac) to help identify Mobile Kayak program participants, and, that this
information will be used to best understand the demographics of the program and
for funding reporting purposes.
I understand that if I am under the age of 18, I must have parent/guardian
authorization to release my contact details to the Atlantic Division, Canadian Canoe
Association, by signing this form.
Photo/ Testimonial / Video Release Section
I understand that the Atlantic Division, Canadian Canoe Association (ADCKC) may
use photograph(s), testimonial (s) and/or video footage that they have taken of me
for any lawful purpose, including for example web content, publicity, advertising
and social media.
I understand that my photograph(s) and/or video footage may be used with or
without my name attached.
I understand that my testimonial (s) may be used with or without my name
attached.
I authorize the Atlantic Division, Canadian Canoe Association (ADCKC) to copyright,
use and publish my photograph(s), testimonial (s) and/or video footage in the
lawful manner describe above.
Atlantic Division CanoeKayak Canada (ADCKC)
PO Box 295, Station Main
Dartmouth NS
(902) 466-9925 www.adckc.ca
I understand that if I am under the age of 18, I must have parent/guardian
authorization to release my photo (s), testimonial (s) and/or video footage to the
Atlantic Division, Canadian Canoe Association, by signing this form.
RELEASE OF LIABILITY, WAIVER OF CLAIMS
ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT
By signing this document you will waive certain legal rights, including the
right to sue.
PLEASE READ CAREFULLY
AWARENESS AND ASSUMPTION OF RISK
I am aware that the Mobile Kayak Program “Lightnings’ Strike” involves risks
including risk of personal injury, death, property damage, expense and related loss,
including loss of income. Included in these risks are negligence on the part of the
Atlantic Division, Canadian Canoe Association (Atlantic Division CanoeKayak
Canada), its directors, officers, officials and volunteers, other participants and
owners of the facilities where the activities occur referred to in the rest of this
agreement as “ADCKC” AND OTHERS. I freely accept and fully assume all such risks
and the possibility of personal injury, death, property damage, expense and related
loss, including loss of income.
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT
In consideration of ADCKC accepting my application to participate in this activity, I
agree:
1. To waive any and all claims that I may have in future against ADCKC AND
OTHERS.
2. To release the ADCKC AND OTHERS from any and all liability for any personal
injury, death, property damage, expense and related loss, including loss of income
that I or my next of kin may suffer as a result of my participation in this activity, due
to any cause whatsoever, including negligence, breach of contract or breach of any
statutory duty of care.
3. To hold harmless and indemnify ADCKC AND OTHERS from any and all liability
for any damage to property of, or personal injury to, any third party, resulting from
my participation in this activity.
4. That this agreement is binding on not only myself but my next of kin, heirs,
executors, administrators and assigns.
Atlantic Division CanoeKayak Canada (ADCKC)
PO Box 295, Station Main
Dartmouth NS
(902) 466-9925 www.adckc.ca
I HAVE READ THIS AGREEMENT AND UNDERSTAND IT. I AM AWARE THAT BY
SIGNING THIS DOCUMENT I AM WAIVING CERTAIN RIGHTS WHICH I OR MY
NEXT OF KIN, HEIRS, EXECUTORS, ADMINISTRATORS AND ASSIGNS MAY HAVE
AGAINST ADCKC AND OTHERS.
PLEASE INITIAL THE FOLLOWING (Guardian must initial and sign if
participant is under the age of 18 years)
☐ Consent to Release Contact, Date of Birth Information
☐ Photo/ Testimonial/ Video Release Form
☐ Release of Liability, Waiver of Claims, Assumption of Risks, and Indemnity
Agreement
Signed this __________________ day of ______________________________________________, 2015.
______________________________________
Witness
__________________________________________
Legal Guardian
______________________________________
Please Print Name Clearly
__________________________________________
Please Print Name Clearly