ACKNOWLEDGEMENT AND ASSUMPTION OF RISK

We ask that you read the text below carefully. This acknowledgement and assumption of risk will be signed in person prior to the activity. 

 

1. RISKS INHERENT TO THE ACTIVITIES

The activities of SKI / SNOWBOARD off-piste I am going to participate in are in a partially marked area, not patrolled, with access to reduced first aid demonstrating a high level of risk that can lead to significant delays in a response of rescue and inconvenience in life-saving practices that may worsen my health.  

The skiable terrain is rugged and can include obstacles such as variable snow conditions, wind slabs, trees, bumps, cliffs, branches, rocks and other inclement weather, requiring prior skiing / snowboarding experience in glades and powder snow of advanced intermediate level ski / snowboard level and more. In addition, access to the territory is done by boot or ski or split-board (with climbing skins) requiring a level of athletic fitness that increases the level of effort and heart rate and increases the risk of serious conditions such as heart attacks, hypothermia, concussions, fractures, trauma and death. Also, the explored territory is rugged and may involve hazards due to variable weather conditions (strong winds, snowstorms, fog, extreme temperature changes, cold water) and the presence of dangerous wild animals (moose, etc.) that may have aggressive behaviour that can potentially attack me.

The risks of the activities to which I am going to participate can more particularly include, while not being limited to:

  • Injuries due to falls or other movements, (sprain, strain, fracture, concussion 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;
  • Presence of wild animals that could potentially attack humans;
  • Limited first aid, which can lead to long intervention times and disadvantages in rescue practices.

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.

Initials please _______________

Parents initials (if less than 16 years of age) __________________

 

2. HEALTH PROFILE

Sex:________ Age: _________

  • Allergies? YES NO
  • Are you pregnant ? YES NO
  • Have you had surgery in the last six months
  • Taking medication? YES NO
  • Do you suffer from a known heart condition that prevents you from participating in sustained physical activity? YES NO
  • Do you feel chest pain on exercise? YES NO
  • Has such pain occurred in recent months? YES NO
  • Do you experience balance problems or do you ever lose consciousness? YES NO
  • Do you have bone or joint problems that can get worse on exercise? YES NO
  • Are you under prescription for blood pressure or heart problems (diuretics or other)? YES NO
  • Do you know of another reason that prevents you from doing physical activity? YES NO
  • Do you suffer, have you ever suffered from : epilepsy, hemophilia, psychiatric disorders (bipolarity, manic depression, borderline personality), severe allergies (nuts, peanuts, biting insects, cold anaphylaxis), asthma, diabetes, AIDS? YES NO

 

  • Initials please _______________

Parents initials (if less than 16 years of age) _________

 

3. IF YOU HAVE ANSWERED YES TO ONE OF THE QUESTIONS IN SECTION 2

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 _________________

Parents initials (if less than 16 years of age) _________

 

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 being 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 _______________

Parents initials (if less than 16 years of age) _________

 

 

5. FIRST AID AND RESCUE PROCEDURES

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 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. 

Initials please _______________

Parents initials (if less than 16 years of age) __________________

 

6. AUTHORIZATION IN CASE OF EMERGENCY

Adult 

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.

Initials please _______________

Parents initials (if less than 16 years of age) __________________

 

7. PERSON TO CONTACT IN THE CASE OF AN EMERGENCY

Name (in bloc letters): ___________________________________________________

Phone number:

___________________________________________________

8. 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). 

Initials please _______________

Parents initials (if less than 16 years of age) __________________

 

SIGNED IN _________________, ON THE ______ DAY OF ___________2018.

Name (in bloc letters): ___________________________________________________ 

Signature: ________________________________________

Parents initials (if less than 16 years of age)

Name (in bloc letters): ___________________________________________________ 

Signature: ________________________________________

 
Electronic signature option
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