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: 

BIRTHDATE (dd/mm/yyyy):

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

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

Consent

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
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

 

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 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

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.

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 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.

Participant 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 sent home 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, death, partial or permanent disability, property damage or loss resulting from my 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, accident, misfortune or damage to the above named or his/her 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, infection, damage or expense whatsoever that might arise out of my 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 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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Lone Prairie Camp https://loneprairiecamp.com
Signature Certificate
Document name: Adult LPC Staff Informed Consent and Waiver Form
lock iconUnique Document ID: 8fa64d04c894fec1d01d25517812d6a956b13c36
Timestamp Audit
May 22, 2020 11:29 pm MDTAdult LPC Staff Informed Consent and Waiver Form Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 69.168.166.218
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