Minor LPC Staff Informed Consent and Authorization Form ({{gravity-field-id-4}})


PLEASE READ CAREFULLY

By signing this form, you are indicating that you have read and understood its contents and give your informed consent. Please clarify any concerns with the Camp Director before signing. This form must be signed and submitted to Lone Prairie Camp prior to your child's participation.

Note: You are not waiving the Participant's rights in the case of negligence and/or malice.

Background Information

TO: Lone Prairie Camp, RR 1, Ferintosh, AB, T0B 1M0 ("LPC") RE: ( - ) (The "Camp")


NAME OF PARTICIPANT:
BIRTH DATE:
NAME OF PARENT(S) GUARDIAN(S): &
CAMP DESCRIPTION: https://loneprairiecamp.com/events/summer-camps/ & Activities listed below
ITINERARY: https://loneprairiecamp.com/downloads/LPC+Summer+Camp+Daily+Schedule

The Participant

I, the Participant 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 understand that I am required to follow all LPC rules, regulations, and guidelines regarding Contagious Illnesses. I shall notify my supervisor 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. 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.

The participant has read and agreed to the above

Consent & Authorization

Activities

I hereby authorize and consent to the Participant’s 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 Participant 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 the Participant 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

If there are any activities that you DO NOT wish for the Participant to participate in, please present a separate letter to the LPC office to that effect.

Medication & Medical Treatment

Allergies:

Medical Conditions:

Medications:

All routine medications will be sent with the participant.

I, the undersigned, give permission to the staff (paid and/or volunteer) of LPC to administer the below indicated
medications (and/or generic versions) to the Participant while participating in the Camp, if and when needed. I also
give permission to the staff (paid and/or volunteer) of LPC to adjust active medical ingredients to weight appropriate
doses in the event that the Participant requires treatment with over-the-counter medication.

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

Yes to:

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 that the Participant 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 the Participant. Further, I understand that LPC carries liability insurance but that LPC is not required to carry no-fault medical/health benefits for the Participant.

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 the participant is 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 the Participant attends 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) the Participant will be required to isolate and will be sent home if he/she exhibit signs of a Contagious Illness, is 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 is exposed to a confirmed case of a Contagious Illness. I agree that if the Participant 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 Participant prior to arrival at LPC and will not send the Participant to LPC if anyone in our household shows signs of a Contagious Illness, Contagious Symptoms, the participant is legally required to isolate, or Alberta Health Services (AHS) has recommended that the participant isolate.

I agree to have the Participant partake in 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 work with Alberta Health Services (AHS) to contact campers and notify 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 the Participant’s information with Alberta Health Services (AHS) for the purpose of contact tracing and notifying of a potential exposure or risk.

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

Discipline

I understand that the Participant must obey the rules established by LPC and its staff (paid and/or volunteer). I agree that if the Participant severely breaches the rules, he or she might be sent home. I agree that if the Participant is sent home under such circumstances, I will be responsible for all associated costs incurred, including the cost of special travel arrangements.

Follow-up Permission

I give permission to LPC to provide my contact information and a brief description of my child's camp experience to my indicated home church or a local church in my area affiliated with LPC. This information will be shared so that the church can inform us of relevant events they may be hosting. However, I understand that the church has agreed that I can unsubscribe at any time.

Acknowledgement

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.

This Consent, Authorization and Acknowledgement shall be effective for the duration of the Camp indicated above.

Leave this empty:

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Signature Certificate
Document name: Minor LPC Staff Informed Consent and Authorization Form ({{gravity-field-id-4}})
lock iconUnique Document ID: d5db3b5ef1e043f3dc954788d38c9e6d26e6aff3
Timestamp Audit
July 22, 2020 10:18 am MDTMinor LPC Staff Informed Consent and Authorization Form ({{gravity-field-id-4}}) Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 68.149.136.16