Adult LPC Staff Informed Consent and Waiver Form


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: Annual Summer Camp ( - ) (The "Camp")

NAME (the "Staff Member"): 

BIRTHDATE (dd/mm/yyyy):

CAMP DESCRIPTION: https://loneprairiecamp.com/download/staff-welcome-letter/

ITINERARY: https://loneprairiecamp.com/download/lpc-summer-camp-daily-schedule/

The Staff Member

I, the Staff Member noted above, understand and agree to obey and comply with safety regulations and instructions as directed by the person(s) in charge of LPC and the Activities. I will not deliberately endanger the safety of myself or others and understand that I can and will be subject to disciplinary action and potentially termination if, in the opinion of the person(s) in charge of LPC and the Activities, I am acting in a manner that could cause a hazard to the safety and well-being of myself and/or others.

I shall notify LPC staff immediately if I experience 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.

The term “staff” is used to refer to both paid and volunteer staff.

Consent

Activities

I fully understand that there are inherent risks to participation in the activities listed below (the "Activities") 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
Arts & Crafts Cuts (eg. scissors), burns (eg. hot glue)
Campfires / Bonfires Burns
Climbing Wall Falling resulting in broken bones, paralysis or death
Field & Wide Games Broken bones, concussions
Initiatives Course / Low-ropes Falling resulting in broken bones, paralysis or death
Pelletry / Riflery Accidentally getting shot, blindness
Skating Concussions, breaking through ice injuries up to and including death
Sledding Falling resulting in broken bones, paralysis or death
Wilderness/Survival Training Cuts (eg. knives), burns (eg. fire)
Zip-Line Falling resulting in broken bones, paralysis or death

 

Reasonable precautions are taken to ensure your health and safety 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
  • 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 you 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

Allergies:

Medical Conditions:

Medications:


I, the undersigned, give permission to the staff (paid and/or volunteer) of LPC to administer an Epipen in case of an emergency where I am 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 myself. Further, I understand that LPC carries liability insurance but that LPC is not required to carry no-fault medical/health benefits for me.

Contagious Illnesses

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and remains a threat to our local health and safety. LPC has responded to the direction to open its facilities and offer services to the community by doing so cautiously, with the safety of participants and staff being its priority. 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, LPC cannot guarantee that participants or staff will not become infected with a Contagious Illness.

I understand that, due to the uncertain nature of the global pandemic caused by Contagious Illnesses, 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 I am required to follow all LPC rules, regulations, and guidelines regarding Contagious Illnesses. I will inform my supervisor immediately if I become aware of any government or local health authority information or directions of which Lone Prairie Camp management may be unaware.

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 the I attend LPC and partake in Activities.

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

I understand that (unless otherwise directed by Alberta Health Services) I will be required to isolate and will be sent home if I exhibit signs of a Contagious Illness, am sick with symptoms or illness (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 am exposed to a confirmed case of a Contagious Illness. I agree that if the I am 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 prior to arrival at LPC and will not attend LPC if anyone in my household shows signs of a Contagious Illness, Contagious Symptoms, I am legally required to isolate, or if Alberta Health Services (AHS) has recommended that I isolate.

I agree to partake in daily assessment and onsite symptom screening to monitor for Contagious Symptoms and Illnesses while attending LPC and partaking in activities

Contact Tracing

In the event of a potential exposure to a Contagious Illness, LPC will work with Alberta Health Services (AHS) to contact Staff Members and participants to notify them of the probable exposure.

LPC will store information related to contact tracing for no less than 2 weeks. Information about Staff Members and 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 information with Alberta Health Services (AHS) for the purpose of contact tracing and notifying of potential exposure.

I will consent to any COVID Testing recommended by Alberta Health Services (AHS) while serving at Lone Prairie Camp and for at least 2 weeks afterwards.

Photo and Video Permission

I give permission to the staff (paid and/or volunteer) of LPC to take photographs and video of me 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.

Staff Member Property

I understand that my 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 to obey and comply with safety regulations and instructions as directed by the person(s) in charge of LPC and the Activities. I will not deliberately endanger the safety of myself or others and understand that I can and will be subject to disciplinary action and potentially termination if, in the opinion of the person(s) in charge of LPC and the Activities, I am acting in a manner that could cause a hazard to the safety and well-being of myself and/or others. I agree that if I am 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, for myself, voluntarily accept and fully assume such risks, dangers and hazards and the possibility of personal injury, infection, illness, death, partial or permanent disability, property damage or loss resulting from my attendance at LPC and participation in the Activities. I 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, infection, illness, accident, misfortune or damage to the above named Staff Member or his/her property, with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above named Staff Member;
  2. any claims, demands, actions and costs for any loss, injury, infection, illness, damage or expense whatsoever that might arise out of my employment and 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 my employment and participation in the Camp.

Acknowledgement & Waiver

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

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Signature Certificate
Document name: Adult LPC Staff Informed Consent and Waiver Form
lock iconUnique Document ID: d0450e9af0c4ae60283e7087038a9dcb5c5da76b
Timestamp Audit
May 22, 2020 11:29 pm MDTAdult LPC Staff Informed Consent and Waiver Form Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 68.149.136.16
May 23, 2020 12:15 am MDT Document owner info@loneprairiecamp.com has handed over this document to registrar@loneprairiecamp.com 2020-05-23 00:15:45 - 68.149.157.40