Family Camp Informed Consent and Waiver Form ({{gravity-field-id-23}})


PLEASE READ CAREFULLY

By signing this form, you are indicating that you have read and understood its contents and that you accept important legal obligations and waive legal rights.

Please clarify any concerns with the Camp Director before signing. This form must be signed and submitted to Lone Prairie Camp prior to your participation.

Background Information

TO: Lone Prairie Camp, RR 1, Ferintosh, AB, T0B 1M0 ("LPC") RE: LPC Family Camp (The "Camp")
NAMES OF ADULTS ATTENDING:
NAMES OF CHILDREN ATTENDING:

CAMP DESCRIPTION: https://loneprairiecamp.com/events/family-camp/ & Activities listed below

ITINERARY: https://loneprairiecamp.com/events/family-camp/

Consent & Authorization

Activities

I hereby authorize and consent to my family members' participation and involvement in the activities of the Camp. I fully understand that there are inherent risks to participation in the activities listed below and LPC’s rural location including, but not limited to, insect bites/ stings, scrapes, sprains & strains, bruises, broken bones etc.

Activities may include but are not limited to, participation in:

ACTIVITY RISKS / POTENTIAL INJURIES
Traveling to and from LPC by means of private and/or LPC transportation Vehicle accident injuries up to and including death
Archery Impalement by an arrow
Arts & Crafts Cuts (eg. scissors), burns (eg. hot glue)
Boating (including as a passenger, tubing & water skiing / wakeboarding) Concussion, paralysis, drowning
Please indicate water skiing / wakeboarding skill level:
Campfires / Bonfires Burns
Climbing Wall Falling resulting in broken bones, paralysis or death
Field & Wide Games Broken bones, concussions
Initiatives Course / Low-ropes
Pelletry / Riflery (must be 12 years or older,
therefore not available during Squirt, Junior or Intermediate camps)
Accidentally getting shot, blindness
Slingshots Accidentally getting shot, blindness
Trampoline Paralysis, death
Water Sports (including swimming, canoeing, paddle-boating & kayaking) Drowning
Please indicate highest swimming level achieved:
Wilderness/Survival Training Cuts (eg. knives), burns (eg. fire)
Zip-Line (not available during Squirt Camp) Falling resulting in broken bones, paralysis or death


I understand that some activities may not be available and that I am not entitled to compensation in this situation.

Reasonable precautions are taken to ensure the health and safety of the Participants including seeking to meet or exceed government and Alberta Camping Association Standards (https://albertacamping.com). These include:

  • Annual zip-line & climbing wall inspections by Association for Challenge Course Technology (ACCT) accredited inspectors and specialized training by the same
  • A designated First Aider with current Standard level First Aid & CPR C certification
  • Current Criminal Record Checks for all volunteer & paid staff 16 or older (https://loneprairiecamp.com/support-us/serve/criminal-record-check/)
  • Safety rules and procedures to be outlined to the Participants prior to participation
  • Passenger vehicles receive annual commercial vehicle inspections
  • LPC, government and local health authority rules and directions regarding COVID-19 and other communicable diseases to be outlined and followed by both staff and Participants

Medication & Medical Treatment

Health Concerns

Please identify any relevant allergies, health problems, medications (including hebals and vitamins) or other health concerns. Indicate if additional information is provided separately.

I shall notify LPC staff immediately if anyone in my family experiences any "Contagious Symptoms" (including but not limited to: cough, fever, runny nose, sore throat, or shortness of breath) not related to a known pre-existing condition.

I, the undersigned, give permission to the staff (paid and/or volunteer) of LPC to administer an Epipen in case of an emergency where a member of my family is unable to administer the Epipen independently.

I understand that illness and injuries sometimes occur through the participation in Activities. In the event that an emergency or other medical treatment is necessary, I consent to and authorize to be transported to the NEAREST SUITABLE MEDICAL HOSPITAL FACILITY. I hereby consent to and authorize emergency or other medical treatment as may be deemed advisable in the event of accident injury or illness during the Camp.

I understand that I am solely responsible to select and purchase adequate medical/health insurance for my family. Further, I understand that LPC carries liability insurance but that LPC is not required to carry no-fault medical/health benefits for my family.

Contagious Illnesses

Lone Prairie Camp’s priority is the health and safety of our campers, rental guests and staff and we are committed to heeding any relevant provincial and federal government restrictions. LPC requires that both Participants and staff follow the directions outlined by LPC, the government and local health authorities to mitigate possible exposure to COVID-19 or to other communicable diseases (“Contagious Illness”). However, the communal living environment of summer camp brings an increased risk for spread of contagious illnesses (e.g. influenza, chicken pox, pink eye, COVID-19, etc.) and LPC cannot guarantee that Participants or Staff will not become infected with a Contagious Illness.

I understand that LPC rules, regulations, and guidelines regarding Contagious Illnesses may change from time to time based on new information and directions provided by government and local health authorities. I further understand that my family members and I are required to follow all LPC rules, regulations, and guidelines regarding Contagious Illnesses.

I understand that despite the precautions taken by LPC in following the directions outlined by government and local health authorities to mitigate exposure to Contagious Illnesses, there is a risk of exposure to Contagious Illnesses while we attend LPC and partakes in activities.

I understand that Participants with a pre-existing condition may be more vulnerable to Contagious Illnesses.

I understand that (unless otherwise directed by Alberta Health Services) Participants will be required to isolate and will be sent home if they exhibit signs of a Contagious Illness, are sick with symptoms or illness identified by AHS (including but not limited to: cough, fever, runny nose, sore throat, or shortness of breath) not related to a known pre-existing condition (“Contagious Symptoms”), or AHS recommends that the Participant isolate due to an exposure to a confirmed case of a Contagious Illness. I agree that if someone from my family is sent home under such circumstances, I will be responsible for all associated costs incurred, including the cost of special travel arrangements.

I agree to honestly complete a Pre-Screening questionnaire on behalf of the my family prior to arrival at LPC and any family members who are legally required to isolate, or Alberta Health Services (AHS) has recommended isolate will not attend Family Camp.

I agree that my family will partake in any required daily assessments and onsite symptom screening to monitor for Contagious Symptoms and Illnesses while attending LPC and participating in activities.

Contact Tracing

In the event of a potential exposure to a Contagious Illness, LPC will follow Alberta Health Services (AHS) directions regarding contacting Participants and notifying them of the probable exposure.

LPC will store information related to contact tracing for no less than 2 weeks. Information about Participants will only be given to Alberta Health Services (AHS) if a potential exposure occurs onsite.

This information is collected by Alberta Health Services (AHS) under sections 20(b), 22(2)(a), & 27(c) of the Health Information Act and sections 22(a) & (c) & 34(1)(a)(i) of the Freedom of Information and Protection of Privacy Act.

In the event of a potential exposure to a Contagious Illness onsite, I give LPC permission to share my family's information with Alberta Health Services (AHS) for the purpose of contact tracing and notifying of a potential exposure or risk.

Photo and Video Permission

I give permission to the staff (paid and/or volunteer) of LPC to take photographs and video of my family and for these Photographs and Video to be used in the future promotion of the activities of LPC, including, but not limited to the posting the Photographs and Videos on the LPC website and brochure and sharing with grant funding sources. LPC cannot control or prevent the further distribution of these images nor of images taken by other participants.

Participant Property

I understand that my family's property may be damaged, lost or stolen during participation in the Camp and that I am not entitled to compensation in this situation.

Behaviour

I, the undersigned, understand and agree that my family will obey and comply with safety regulations and instructions as directed by the person(s) in charge of LPC and the Activities. We will not deliberately endanger the safety of ourselves or others and understand that we can and will be sent home if, in the opinion of the person(s) in charge of LPC and the Activities, we are acting in a manner that could cause a hazard to the safety and well-being of myself and/or others. I agree that if we are sent home under such circumstances, I will be responsible for all associated costs incurred, including the cost of special travel arrangements.

Disclaimer and Release of Liability

I on behalf of myself, my spouse and my dependants, voluntarily accept and fully assume such risks, dangers and hazards and the possibility of personal injury, death partial or permanent disability, property damage, or loss resulting from our participation in the Activities.

I on behalf of myself, my spouse and my dependants, release, indemnify and hold harmless LPC and the Baptist General Conference in Alberta (BGCA), and each of their respective trustees, directors, officers, corporation members, employees, agents, volunteers, consultants, successors, insurers, members, representatives, assigns and subsidiaries from:

  1. any loss, personal injury, accident, misfortune or damage to the above named or our property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above named;
  2. any claims, demands, actions and costs, for any loss, injury, damage, or expense whatsoever that might arise out of my family's participation in the Camp and the Activities; and
  3. any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from our participation in the Camp.

Acknowledgement & Waiver

I understand that this is a legal agreement that is binding upon myself, my heirs, executors, administrators, successors and assigns. I acknowledge that I have read and understand the terms of this agreement and acknowledge that by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that I may have.

This Consent, Disclaimer and Release of Liability & Acknowledgement and Waiver shall be effective for the duration of the Camp indicated above.

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Signature Certificate
Document name: Family Camp Informed Consent and Waiver Form ({{gravity-field-id-23}})
lock iconUnique Document ID: 4420b14d7366605583da04c395cfd58d045f4417
Timestamp Audit
July 20, 2020 4:57 pm MSTFamily Camp Informed Consent and Waiver Form ({{gravity-field-id-23}}) Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 69.168.164.64