ACKNOWLEDGEMENT AND ASSUMPTION OF RISK
We ask that you read carefully the text below. This acknowledgement and assumption of risk will be signed in person prior to the activity.
- RISKS INHERENT TO THE ACTIVITIES
The activities of SKI/SNOWBOARD OFF-PISTE in which I am going to participate are in a partly marked, non-patrolled area with reduced first-aid access demonstrating a high level of risk. The ski area is rugged and can include obstacles such as powdery snow of variable conditions, wind patches, trees, bumps, branches, rocks, cliffs, and other obstacles, requiring a previous experience of ski/snowboarding in glades and a level of ski/snowboard of advanced intermediate caliber and higher. In addition, the access to the territory is done either by boot pack or by ski or split-board (with ascension skins) requiring a level of athletic physical condition. I acknowledge that I have been informed about the risks inherent with the activities that are part of the WHISJACK Mountain and Adventure Centre program, property of All Mountain Lab inc.. The risks of the activity of SKI / SNOWBOARD to which I am going to participate can more particularly include, while no being limited to:
- Injuries due to falls or other movements, (sprain, strain, fracture, etc.);
- Injuries with blunt or sharp object (trees, rocks, branches, material, etc.);
- Cold or hypothermia;
- Injuries resulting from accidental or other contact between individuals;
- Food allergy;
- Contact with water and potential drowning (near a watercourse);
- Unusual downtimes and constraints of movement within the territory;
- Limited first aid, which can lead to long intervention times and disadvantages in rescue practices.
Initials please _______________
Parents initials (if less than 16 years of age) __________________
2. HEALTH PROFILE
Sex:________ Age: _________Allergies? YES / NOIf yes, specify:_____________________
Are you pregnant? YES / NO If yes, how many months? _______________________________
Taking medication? YES / NO If yes, specify medication name(s) and treatment dosage ______
Do you have physical, emotional or behavioural problems that could limit your participation in your chosen activity, such as respiratory and/or cardiac problems, diabetes, vision or hearing problems, fear of water / heights / dogs, limitation of movements, etc.) YES / NO. If yes, specify:
Initials please _______________ Parents initials (if less than 16 years of age) _________
PLEASE NOTE: Having discussed my medical condition with a person in charge at WHISJACK I agree and accept the additional risk that my health condition may be aggravated by participating in the activity. Initials please _________________
4. DRUGS AND ALCOHOL
I promise to not consume, not have in possession, or be under the influence of any drugs (prescription or otherwise) or illegal substances which are not mentioned in point 2 of this form. I also confirm not bing under the influence of alcohol (below the limit of 80 mg alcohol per 100 ml of blood, commonly called "zero point eight"), and remain so for the entire duration (activity / trip / stay). I am aware that any violation of these rules on my part might evict me from the activity/ trip/ stay without notice and without refund.
Initials please _______________
CONFIRMATION OF INFORMATION AND ASSUMPTION OF RISKS
I hereby certify that the information consigned to this Form is, to the best of my knowledge, exact and accurate. I further certify that no information pertinent or not to my health profile was deliberately omitted. I am aware that the information contained in this Form is confidential and will be used to better plan and supervise the safety of the activities in which I will participate and will allow WHISJACK to draw up a profile of its clientele. I am also aware that the activities offered by WHISJACK take place in semi-wild or natural environments that, consequently, are quite distant from medical services. I am aware that the responsibility of WHISJACK is limited to that of an accompanying-guide. In the case of an incident, WHISJACK will refer to the Massif de Charlevoix’ Patrol services to undertake the first aid and rescue. This state of affairs could result in long delays during an emergency requiring an evacuation and, as such, a possible aggravation of my state of health or my injury. Having taken cognizance of these risks and having had the opportunity to discuss them with a person responsible for the activity, I acknowledge that I was informed about the risks inherent to the activities and I am able to participate in the activity or the stay WILLINGLY AND I ACCEPT ANY AND ALL RISKS THAT such an activity or stay can comprise. I also pledge to play an active role in risk management by adopting a preventive behaviour with regards to my own safety, and the safety of the other persons that surround me. The guide reserves the right to exclude any person he/she deems to be a risk to himself/herself or to the rest of the group. I understand that I may leave the present activity for any reason whatsoever.
Name of participant (in bloc letters):_________________________________________
Signature: ___________________________________________Date: _____________
Parents name (if less that 16 years of age, bloc letters)__________________________
Parents signature (if less that 16 years of age): _______________________________
MATERIAL LIABILITY WAIVER
I, undersigned, forego to any claim, proceeding in damage or interest for damages to assets and material of my belonging (attrition, loss, breakage, theft, vandalism).
Name (in bloc letters): ____________________________________________________
Signature: _________________________________________Date: _______________
AUTHORIZATION IN CASE OF EMERGENCY
I, undersigned, authorize WHISJACK to provide all necessary care. I also authorize WHISJACK to make decision in case of an accident to transport me (by ambulance, helicopter, coast guard or other) to a hospital or health care center, and this, at my own expense.
Name (in bloc letters): ___________________________________________________
Signature: ________________________________________Date: ________________