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 understand 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 fully understand that there are inherent risks to participation in the activities listed below due to 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 (http://www.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
  • Emergency First Aid training during our pre-summer Staff Training Week & a designated First Aider with current First Aid certification
  • Current Criminal Record Checks for all volunteer & paid staff 16 or older (https://loneprairiecamp.com/support-us/serve/criminal-record-check/)
  • Safe rules and procedures to be outlined to the Participants prior to participation
  • Passenger vehicles receive annual commercial vehicle inspections

Medication & Medical Treatment

Health Concerns

Please identify any relevant allergies, health problems, medications or other health concerns. Indicate if additional information is provided separately.

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 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.

I also understand that although Lone Prairie Camp seeks to abide by all government regulations related to infectious disease risk mitigation, there is a risk of contracting an illness while at Lone Prairie Camp. I will inform my supervisor immediately if I become aware of any government guidelines of which Lone Prairie Camp management may be unaware.

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.

Leave this empty:

Signature arrow
Lone Prairie Camp https://loneprairiecamp.com
Signature Certificate
Document name: Family Camp Informed Consent and Waiver Form ({{gravity-field-id-23}})
lock iconUnique Document ID: a4109bfc67c642613eabc4d170a4a31caadd93a9
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 69.168.162.91