Minor LPC Staff Informed Consent 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 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.

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.

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
  • 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 Participant prior to participation
  • Passenger vehicles receive annual commercial vehicle inspections

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.

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 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.

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Lone Prairie Camp https://loneprairiecamp.com
Signature Certificate
Document name: Minor LPC Staff Informed Consent Form ({{gravity-field-id-4}})
lock iconUnique Document ID: e44c5fa09c0bfda3a231b59c5f06999505721674
Timestamp Audit
July 22, 2020 10:18 am MSTMinor LPC Staff Informed Consent Form ({{gravity-field-id-4}}) Uploaded by LPC Registrar - registrar@loneprairiecamp.com IP 69.168.166.218