Breaking Barriers registration form

Breaking Barriers registration form

October 11th, 11 am - 4 pm
We will be using this information to register your child for our Breaking Barriers event at Wero. Please carefully read the acknowledgement form and terms and conditions here: Wero Acknowledgement form
Do you consent to the information requested in the Wero Acknowledgement form to be shared with Wero Whitewater Park*

I consentI do not consent (please email ainiekwok@gmail.com to discuss)

Parent/Guardian contact details

This will also be used as emergency contact details
Parent/Guardian full name and relationship to participant *
Parent/Guardian email address*
Parent/Guardian mobile phone number*

Participant details
Participant full name*
Participant Date of Birth*

DayMonthYear
Date
Participant weight (for safety purposes)*
in kg, e.g 79 kg
Participant height (for safety purposes)*
in cm, e.g 155 cm
Participant first language (everyday use)*
Medical and / or Physical condition: Please describe the nature of that condition and the effect it may have on these activities. Please also inform any first aid or emergency medical treatment that the participant may require*
e.g Down Syndrome, ADHD. Refer to the Wero Acknowledgement form for more details
Is the participant currently on any medication?*

NoYes, please specify
Any dietary requirements?*
Contact through? (where did you hear about this event)*
School*
Final consent
Would you like to receive further information from the Park via electronic messages such as email, text and SMS to keep me up to date with special events, offerings, and Park updates?*

YesNo
Do you consent to your child's photos being taken?(Waka Pacific Trust may occasionally film or take photo of participants for publicity purposes, which may include reproducing images on the Trust’s, the Park’s and/or Partners websites or social media pages or accounts i.e Facebook, Instagram, YouTube, etc. I agree to the use of photos or footage that includes myself, my child, or my group. Rotary will also be taking photos and may share these with the supporting Rotary clubs)*

YesNo
RISK ACKNOWLEDGEMENT

This activity is an adventure activity with a degree of risk which varies between activities. Participants should be aware that the commercial operator cannotguarantee your safety. Canoeing, kayaking, rafting, climbing/high ropes and other activities available at the Park carry inherent risks. These include but are notlimited to cuts, abrasions, sunburn, impact injuries, physical exertion, dehydration, inhalation of water, the potential for physical contact with other persons and/orcourse equipment, ejection from the water craft, and physical contact with course infrastructure. This may result in injury or even death.

AGREEMENT TO TERMS AND CONDITIONS
I have read and understand the Wero Whitewater Park terms and conditions (see reverse) and I will comply with all of them, all signage, and the instructions and directions of the Park and/or Park staff at all times. If I am completing this form for a person under eighteen (18) years old I confirm that I am that young person's parent or guardian or that I am otherwise responsible for him/her while at the Park.
Parent/Guardian signature to accept the Risk Acknowledgement, Terms and Conditions and confirm that information provided is accurate*
Should be Empty:

Breaking Barriers registration form

Parent/Guardian contact details

Participant details

Final consent