Paddling the Bogan River Registration Form
Please note: Participants must be 12-24 years of age
1. Participant Details
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Day
-
Month
Year
Date
Email
example@example.com
Phone Number
*
2. Please fill out if the Participant is under 18 years of age. If not, skip to section 3.
Parent/Carer Name
First Name
Last Name
Parent/Carer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Alternate Phone Number
3. Further Information
1) Does the participant have any health issues or injuries that may impact their use of stand-up paddleboards or kayaks? If yes, please specify:
*
2) Does the participant take medication that will impact their use of stand-up paddleboards or kayaks?
*
Yes
No
3) Can the participant swim at least 50 metres unaided?
*
Yes
No
4) Does the participant hold any lifesaving or water safety qualifications? If yes, please specify:
*
5) Does the participant have any allergies or dietary requirements? If yes, please specify:
*
Which sessions will the participant attend?
*
Upper Weir: Saturday 19th Feb, 9am-12pm
Upper Weir: Saturday 19th Feb, 4pm-7pm
Lower Weir: Tuesday 22 Feb, 4pm-7pm
Lower Weir: Friday 25 Feb, 4pm-7pm
Please note:
This event will be run under COVID-19 safety protocols that all attendees must comply with for their safety and the safety of others. Sunscreen and water will be supplied, but participants are encouraged to bring their own hats.
PARTICIPANT TO SIGN
I understand that in all water sports there are associated risks and I am aware of such risks, noting that the organisers have put into place strategies that are intended to mitigate these risks. I understand and agree that I need to follow the direction of the supervisors to ensure my own safety and the safety of all participants, and my failure to do so will lead to my exclusion from the paddle boarding and kayak activities.
*
I have read this waiver and agree.
I have read this waver and do not agree.
Name
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
Signature
*
PARENT/CARER TO SIGN (if the participant is under 18)
þ
I have read this waiver and agree.
I have read this waiver and do not agree.
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Signature
Back
Next
Medical Advice
To be filled out by my parent/carer if the participant is under 18 years of age.
Participant Medical Details
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Emergency Contact's Relationship to Participant
I give permission to call an Ambulance in an emergency:
*
Yes
No
Medicare Number
Please select any health conditions the participant suffers from, and explain the management of them below:
*
Diabetes
Asthma
Epilepsy
Bronchitis
Allergies (please list below)
Other (please specify below)
None
Please select the symptoms the participant experiences during physical activity, and explain the management of them below:
*
Undue shortness of breath
Chest pain
Lightheadedness, dizziness or episodes of fainting
Becomes tired/fatigued easily
Other (please specify below)
None
Participant's previous injuries:
*
Fracture
Dislocation
Neck injury
Back injury
Ankle sprain
Knee problems
Other (please specify below)
None
Any regular medication or current medication (please supply details i.e. reason for medication, times,etc.).
Any physical, i.e. muscular/joint problems that may limit the participant in physical activity.
Any other conditions/ailments that supervisors should be aware of.
*
I declare this to be a true statement of my own/mychild/ward’s health status as at the date below.
FOR PARTICIPANTS UNDER 18
Parent/Carer Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Signature
FOR PARTICIPANTS OVER 18
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Signature
For any further information or enquiries, please contact Olivia Ashton, Bogan Shire Council: Ph: (02) 6835 9019 E: olivia.ashton@bogan.nsw.gov.au
Submit
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