Adult LPC Staff Informed Consent and Waiver Form
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.
TO: Lone Prairie Camp, RR 1, Ferintosh, AB, T0B 1M0 ("LPC") RE: Annual Summer Camp ( - ) (The "Camp")
NAME (the "Staff Member"):
CAMP DESCRIPTION: https://loneprairiecamp.com/download/staff-welcome-letter/
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.
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:
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:
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.
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.
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.
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.
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.
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:
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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If you have questions about the contents of this document, you can email the document owner.
Document Name: Adult LPC Staff Informed Consent and Waiver Form
Agree & Sign