YL - RockRidge Canyon Informed Consent & Health Information

YOUNG LIFE OF CANADA - ROCKRIDGE CANYON INFORMED CONSENT AND HEALTH INFORMATION
Young Life staff, leaders and volunteers MUST complete all spaces and sign this form prior to participation in any activities at RockRidge Canyon. Staff and volunteers under the age of 19 must have this form signed by a parent or legal guardian.
Young Life area:
Full Name

First NameLast Name
Current Year at RockRidge Canyon
either the current year for the annual renewal for Young LIfe staff and volunteers OR the event dates for others.
Cell Phone
Format: (000) 000-0000.
Mailing Address
City
ProvinceState
PostalZip Code
MSP Prov Health Care
Birth Date (DD/MM/YYYY)

DayMonthYear
Date
Gender
Parent Guardian or Spouses Name
Emergency Contact
Emergency Cont. Phone #(s)
Format: (000) 000-0000.
PLEASE READ CAREFULLY. SIGNING THIS FORM WAIVES CERTAIN LEGAL RIGHTS

Initial all paragraphs to confirm you have read, understand, and agree.
MEDICAL TREATMENT I hereby give permission to a qualified practitioner appointed by Young Life of Canada (YLC) to provide medical treatment within their scope of practice I also agree to be transported to a local hospital in a medical emergency if I am not able to give verbal consent. I also agree to consult a healthcare professional should I be reasonably requested to do so by YLC
COVID-19 AND OTHER INFECTIOUS DISEASES: I understand that COVID-19 and other infectious diseases remain a potential risk to which I may be exposed while visiting this YLC property. I understand and agree that YLC will follow all current and applicable public health protocols and I agree to follow all such public health protocols while I am at this YLC property.
HEALTH COVERAGE: I agree to provide YLC with evidence of current medical coverage under BC Medical or equivalent. I understand that I may be billed for medical expenses not covered by my Provincial Health Plan, my extended medical coverage, or my personal insurance plan.
ASSUMPTION OF RISKS: I understand YLC has undertaken to ensure the recreational activities provided to me which may include such activities as wide games, land and water sports, swimming, and diving, ziplining, dancing etc are as safe as reasonably possible. I understand there are inherent risks based on my involvement in such activities. I understand that it cannot be guaranteed that I will not be injured as the result of participating in the activities. I also understand YLC cannot guarantee a food-allergy-free environment.

I have provided to YLC my medical contact information, and complete lists of all my known allergies, medical dietary restrictions, and current and past medical conditions, with appropriate detail and a list of medical treatments and restrictions which will apply while I am at a YLC property (my disclosed pre-existing conditions).

I also confirm that I have no knowledge of any other physical or mental impairment that would be affected by, or affect, my participation in the activities at a YLC property and believe that I am physically, mentally, and emotionally able to do so.

I choose to accept all risks of injury to myself (including: personal injury, disability or death, illness, damage, loss) or claim liability or expense of any kind (claims, including any claims based on the actions, omissions or negligence of any YLC director, officer, employee, agent or representative) which may result, arise out of or occur in connection with (a) my participation in the activities, (b) my exposure to allergens (c) a pre-existing health condition of any kind, whether or not disclosed to YLC and (d) my physical, mental or emotional abilities.
BEHAVIOUR AND DISMISSAL I will follow all the requirements for visiting, camping and participating in activities at this YLC property and the reasonable directions of all volunteers and employees of YLC. The Director of this YLC property or designate reserves the right to dismiss a guest without refund who in his/her opinion is a hazard to the safety of others or who appears to have rejected the reasonable behavioral rules of this YLC property. I hereby give permission to the Director or designate to search my belongings or personal effects for prohibited items if am reasonably suspected of having same. I agree to reimburse YLC for damage to or defacement of property attributable to my activity.
PROMOTIONAL: I give permission to YLC or its designate to take and use photos, videos, or any other recording of me for use in promotional materials or camp videos, in any format now known or later devised, and YLC or its designate may use my name in connection with such uses.
LOST ITEMS: YLC is not responsible for personal items which are lost, stolen or damaged. Shipping of my found items, if any, will be at my own expense.
RELEASE AND WAIVER OF LIABILITY: I, for myself and my family members, estate, heirs, personal representatives and assigns, if any, release covenant not to sue, and waive any and all liability against, and will not hold or seek to hold YLC or its directors, officers, employees, agents and representatives liable for any sickness, illness, injury or infection or claims (including any claims based on the actions, omissions or negligence of any YLC director, officer, employee, agent or representative) that result from, or arise out of, or in connection with (a) my participation In the activities, (b) my exposure to allergens (c) a pre-existing health condition of any kind, whether or not disclosed to YLC and (d) my physical, mental or emotional abilities, whether or not such claims arise before, during, or after my visit to this YLC property.
INDEMNITY: I will save and hold harmless the Directors, Officers, and all volunteers, employees of YLC and any or all of their affiliates from any and all actions, causes of action, claims and demands resulting from any loss, illness, sickness, injury or damage to my person or my property which has arisen, or may arise from a visit to, camping or living at, or my participation in any activities at this YLC property including any YLC programs, travel, activities, or otherwise.
JURISDICTION: I understand any and all actions that may arise from this agreement or my camping, visiting, or living at this YLC property will be governed by the laws of British Columbia, Canada and I consent to the exclusive jurisdiction of the courts in British Columbia,
Initial all paragraphs to confirm you have read, understand and agree
By signing below, I acknowledge that I am 19 years old, or older, and that I have read, understood and voluntarily agree to all the terms of this Waiver and Consent to Medical Treatment, including that I am choosing to accept all risks of my participation in any and all aspects of activities at this YLC property, waiving liability on the terms set out above against YLC, and that I am giving informed consent to medical treatment should such need arise.
Guest Signature
Date

MonthDayYear
Date
Note: Parent or Legal Guardian signs on the second page for guests under the age of 19.

Young Life Camps Informed Consent 01/24
INFORMED CONSENT AND HEALTH INFORMATION - YOUNG LIFE OF CANADA
Guest Full Name
If the Guest is not 19 years old or older, the parent(s) or legal guardians(s) have submitted this form on behalf of the Guest, and consent to the Guest attending this YLC property, and: 1. Have legal custody of the Guest. If a custodial order is in place, this will be fully communicated to YLC including a photocopy of the section of any court order referring to visitation rights. 2. Understands that references to "I" or "the Guest" are to be read and understood as references to myself as the parent/legal guardian. 3. Have read, understood and voluntarily agree to all the terms of this Waiver and Consent to Medical Treatment set out above, including that the parent/guardian, on their own behalf and on behalf of the Guest: (a) accepts all risks of the Guest's participation in any and all aspects of the activities at a YLC property (b) on the terms set out above: (i) waives liability against YLC (ii) gives informed consent to medical treatment should such need arise; and (d) saves and holds harmless the Directors, Officers, and all volunteers, employees, agents and representatives of YLC and any or all of its affiliates from any and all actions, causes of action, claims and demands resulting from any loss, illness, sickness, injury or damage to the Guest's person or property which has arisen or may arise from visit to, camping or living at, or my participation in any activities at this YLC property including any YLC programs, travel, activities, or otherwise.
Parent Legal Guardian Name
Signature
Date

DayMonthYear
Date
Address
Email Address
example@example.com
Phone
Format: (000) 000-0000.
HEALTH CARE INFORMATION - REQUIRED FOR MEDICAL STAFF
This section is to be completed by a parent or guardian for guests under the age of 19. It is the responsibility of the guest, parent, or guardian to notify RockRidge Canyon, in writing, if any new medical issues or conditions arise prior to arrival (e.g., exposure to a communicable disease, etc
Name of Family Physician
Office Phone
Format: (000) 000-0000.
Foreign only: Medical Insurance Company or Extended Health Plan Address of Insurance Co.
Address of Insurance Co
Phone
Format: (000) 000-0000.
Food Allergies and Dietary

RockRidge Canyon is conscientious of nut allergies but is not a nut-free facility.• We can accommodate mild to moderate special diets and allergies, such as: Gluten Friendly (please indicate if Celiac), Dairy Friendly (please indicate if it can be consumed in baking) Peanut/Tree Nut - Fish/Shellfish - Vegetarian, Vegan• Due to the open nature of our kitchen, cross-contamination may occur.• We cannot accommodate halal, or kosher requests, nor personal diets such as paleo, keto, carnivore diet, pescitarian, etc.
Do you have any dietary needs or food allergies

Dietary Needs & Food Allergies

Rows	Selection	Reaction (If Life Threatening)	Additional Information
Vegetarian
Vegan
Celiac
Gluten
Dairy
Soy
Egg
Nuts
Sulfites
Shellfish
Seafood
Vegetables (List in Additonal Information)
Fruit (List in Additonal Information)
Seeds
Other

If needed, please provide extra details for our food services staff regarding allegeries or dietary needs
Check all immunizations that are up to date:

DPT (Diphtheria/Pertussis/Tetanus)

Check any medical conditions - (C) current or (P) past

Bleeding condition Digestive condition Recent injury

Recommendations and Restrictions while at Camp
Check all immunizations that are up to date
Check any current medical conditions
Are there any other conditions or past conditions to note
Provide detail
Treatments/medications to be continued while on property (be specific)
Activities to be limited
Additional information that the doctor or property should be aware of
Should be Empty:

YOUNG LIFE OF CANADA - ROCKRIDGE CANYON INFORMED CONSENT AND HEALTH INFORMATION

HEALTH CARE INFORMATION - REQUIRED FOR MEDICAL STAFF

Food Allergies and Dietary