Nihtat Gwich'in Council - Educational & Cultural Programs

NIHTAT GWICH'IN COUNCIL

EDUCATIONAL & CULTURAL PROGRAMS

MEDIA CONSENT FORM
I, First Name * Last Name * confirm that I am at least 19 years old, and (i) I am the person identified as the Participant below and completing this Media Consent Form for myself; or (ii) I am the parent or legal guardian of my child or ward identified as the Participant below and I am authorized to complete this Media Consent Form on their behalf.
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I, First Name * Last Name * hereby consent on my own behalf and on the behalf of my child/ward First Name* Last Name*to be interviewed, recorded, photographed and videotaped by the Nihtat Gwich'in Council (“NGC”) or its employees, volunteers, representatives or agents for purposes of publication or display whether print, web or other forms of media (the “Media”). I further consent to the use, reproduction and publication of such Media of me and/or my child/ward.
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I acknowledge that NGC cannot control unauthorized use of the Media by the public once the Media has been published.

I agree that all Media shall be the sole property of NGC and I forever discharge any present or future claim for reimbursement of the same.

I HEREBY RELEASE NGC, ITS EMPLOYEES, VOLUNTEERS, MEMBERS, REPRESENTATIVES AND AGENTS FROM ANY AND ALL CLAIMS, DEMANDS, COSTS AND LIABILITY THAT MAY ARISE FROM THE COLLECTION, USE AND REPRODUCTION OF THE MEDIA.
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By initialing the fields above and clicking “I consent” and providing my electronic signature below, I agree that I have read this consent form in its entirety, I have had the opportunity to ask questions about it and I accept and agree to be bound by the terms and conditions of the consent and release that have been provided by me herein.

If you have any questions about this Media Consent Form as referenced above, please contact Nihtat Gwich'in Council 9 Bompas, P.O. Box 2570, Inuvik NT X0E 0T0, (867) 777-6650 or email reception@nihtatgwichin.ca
Full Name of Participant

First NameLast Name
Full Name of Parent/Guardian

First NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

NIHTAT GWICH'IN COUNCIL

EDUCATIONAL & CULTURAL PROGRAMS

ASSUMPTION OF RISKS, RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT

(hereinafter, the “Release Agreement”)
I, First Name * Last Name * confirm that I am at least 19 years old, and (i) I am the person listed as the Participant below and am completing this Release Agreement for myself; or (ii) I am the parent or legal guardian of my child or ward listed as Participant below and I am authorized to complete this Release Agreement on their behalf.

In this Release Agreement, the term “Program” shall include any and all activities, events, socials, classes, programs, workshops, demonstrations and other services provided, organized, conducted, sponsored or authorized by Nihtat Gwich'in Council (“NGC”) in relation to its Education and Cultural Programs.

I understand that NGC is relying on the completion of this Release Agreement in allowing the Participant to participate in the Program.

Voluntary Participation
I confirm that the Participant’s participation in the Program is voluntary.
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Assumption of Risks

I understand there are many risks and hazards inherent in the Participant’s participation in the Program including but not limited to: unwanted interaction including physical contact from other participants, use of equipment and tools including but not limited to bicycles, rope, knives, fishing rods and hooks, ice augers, stoves and cooking utensils; riding and/or operating a snowmobile, vehicular travel to and from NGC property, hiking on and off of NGC property in wilderness areas, proximity to and activities on lakes, oceans, rivers and other unpatrolled bodies of water, exposure to extreme and/or changing weather conditions, travel on highways and backcountry roads, handling of and exposure to different plants, funghi and insects; and encounters with domestic and wild animals including but not limited to dogs, coyotes, moose, bears and cougars. Participation in such activities could lead to loss of or damage to personal belongings, physical injury, illness, wounds, sunburn, sun stroke, frost bite, muscular or soft tissue strains, sprains and tears, broken bones, burns, eye injury or loss, allergic reactions, dehydration, concussions, paralysis, infections, drowning and death.

I AM AWARE OF, FREELY ACCEPT AND ASSUME ALL OF THE RISKS AND HAZARDS ASSOCIATED WITH THE PROGRAM AND THE POSSIBILITY OF INJURY, ILLNESS, DEATH, PROPERTY DAMAGE AND ANY LOSS(ES) RESULTING THEREFROM.
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Release of Liability and Waiver

In consideration of NGC permitting the Participant to participate in the Program, use NGC’s equipment, machinery, tools and facilities and access NGC’s property,

I, {fullName94} HEREBY WAIVE ANY AND ALL CLAIMS I AND/OR THE PARTICIPANT MAY HAVE AGAINST, AND RELEASE ALL LIABILITY AGAINST AND AGREE NOT TO SUE NGC, ITS EMPLOYEES, VOLUNTEERS, REPRESENTATIVES, MEMBERS OR AGENTS, FOR ANY PERSONAL INJURY, ILLNESS, DEATH, PROPERTY DAMAGE OR OTHER LOSS SUSTAINED BY ME OR THE PARTICIPANT IN CONNECTION WITH THE PARTICIPANT’S PARTICIPATION IN THE PROGRAM, DUE TO ANY CAUSE WHATSOEVER, INCLUDING NGC’S NEGLIGENCE, NEGLIGENT MISREPRESENTATION OR ANY BREACH UNDER ANY LEGAL THEORY.
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Indemnification

I, First Name * Last Name * hereby indemnify, defend and hold harmless NGC its employees, volunteers, representatives, members and agents, for any and all damages, losses, costs, expenses, liabilities, claims, demands, action, of any nature which NGC, its employees, volunteers, representatives, members, agents or any other third party may suffer as a result of the Participant participating in the Program.
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Miscellaneous

I,   First Name *   Last Name *  understand:

1.   This Release Agreement shall be effective and binding upon my and the Participant’s heirs, next of kin, executors, administrators, assigns and representatives.

2.   This Release Agreement and any rights, duties and obligations as between the parties to this Agreement shall be governed by and interpreted solely in accordance with the laws of the North West Territories and federal laws of Canada, applicable therein.

3.   If any provision of this Release Agreement is wholly or partially unenforceable for any reason, such enforceability shall be deemed not to affect the enforceability of the balance of this Release Agreement.
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Select to Agree
By initialing the fields above, clicking “I consent” and providing my electronic signature below, I CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS RELEASE AGREEMENT PRIOR TO SIGNING IT, AND I AM AWARE THAT BY SIGNING THIS RELEASE AGREEMENT I AM, FOR MYSELF AND THE PARTICIPANT WAIVING CERTAIN LEGAL RIGHTS THAT I AND THE PARTICIPANT AND OUR RESPECTIVE HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATIVES MAY HAVE AGAINST NGC, ITS EMPLOYEES, VOLUNTEERS, REPRESENTATIVES, MEMBERS AND AGENTS INCLUDING THE RIGHT TO SUE.
Full Name of Participant

First NameLast Name
Full Name Parent / Guardian

First NameLast Name
Signature of Parent/Guardian
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NIHTAT GWICH'IN COUNCIL

EDUCATIONAL AND CULTURAL PROGRAMS

EMERGENCY CONTACT FORM AND AUTHORIZATION FOR EMERGENCY

MEDICAL CONSENT
Emergency Contact Details
Full Name of Participant

First NameLast Name
Full Name Parent / Guardian

First NameLast Name
Parent / Guardian Phone Number
Full Name of Primary Emergency Contact

First NameLast Name
Phone Number for Primary Emergency Contact
Relationship of Participant to Primary Emergency Contact
Full Name of Secondary Emergency Contact

First NameLast Name
Phone Number for Secondary Emergency Contact
Relationship of Participant to Secondary Emergency Contact
Does your child/youth have any allergies or other significant health conditions? If so please provide details in the space below:
Signature (Parent/Guardian)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization For Emergency Medical Treatment

In the event emergency medical aid treatment is required due to illness or injury in connection with the Program, I  First Name*   Last Name*  authorize any adult associated with NGC to:

1.     Secure and retain medical treatment and transportation if needed; and
2.    Release records upon request to the authorized individuals or agency involved in the medical emergency treatment.

This authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed ‘life saving’ by a first responder, nurse, or physician. This provision will only be invoked if the Primary and Secondary Emergency Contacts listed above are unable to be reached, having regard to the circumstances.

Subject to any allergies specified above, I further authorize any adult associated with NGC to administer bandages, burn cream, antihistamine, acetaminophen, sunscreen and insect repellant as requested by the Participant and/or deemed reasonably necessary.

By clicking "I consent" and providing my electronic signature below, I  First Name *   Last Name *  authorize this Authorization for Emergency Medical Treatment.
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Signature (Parent/Guardian)
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Should be Empty: