Qi AC: Membership Form

Qi AC Membership Form

Qi Creative Inc. • Qi Adventure Club
Young Master Club (Taekwondo)Qi Climbing (Wall Climbing)Qi Rides with You 2 (Bicycle Riding)Qi RPG (Tabletop Role Playing Games)
Particpant's Name:*

First NameLast Name
Participant's or Guardian's Email:*
This is to follow up on any future Adventure Club programs
Participant's or Guardian's Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Participant's Birthdate:*

MonthDayYear
Date
Participant's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Please provide the participant's Insurance Information:*
Insurance Company, Policy/Certificate #
YesNo
Authorized Persons:*
These persons are authorized to pick up the participant.

Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Secondary Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email:*
example@example.com
Emergency Contact Relationship to Participant:*

Communication
YesNo
I understand
I agree

Participant Member Code of Conduct
Respect Yourself

Qi Adventure Club expects that you are able to:
- Use the washroom without assistance
- Perform proper hygiene
- Eat on your own
If the participant is unable to perform one or more of the self-care points above, they must require a support worker or aide to join the program.

Qi Adventure Club expects that as a participant you will:
- Arrive on time
- Be willing to challenge yourself to try new activities that may be outside of
  your comfort zone
- Understand that you have the right to sit out of any activity you do not feel
  comfortable participating in
Respect Others

Qi Adventure Club expects that you will treat each participant,
volunteer and coach with respect by:
- Giving others their personal space
- Listening when someone else is talking
- Using positive and uplifting language
- Helping and encouraging those who may need extra support
Respect the Environment

Qi Adventure Club expects that you will:
- Practice the Leave No Trace Principle, which means that when we are outside,
  you will take everything you bring on the program back home with you (including garbage)
- Respect living animals, plants and insects while on the program by
  not disturbing them in their natural habitat
- Take care and use rental equipment appropriately (if applicable)
These rules are in place to ensure the enjoyment and inclusivity of Qi Adventure Club. If any of the above rules are broken while on a Qi Adventure, appropriate measures will be taken individually to ensure the club’s safety and enjoyment.
I understand

Assumption of Risk
In consideration of being allowed to participate in any way in Qi Creative Inc (hereinafter called ‘Qi') programs, and related events and activities, or serve as staff or volunteer for the same, I, and/or the minor participant, and/or person for which I am the legal guardian, the undersigned:
Understand that although Qi has taken precautions to provide proper organization, supervision, instruction, and equipment for each activity, course, & program (all of hereinafter called ‘Adventure’). It is impossible for Qi to guarantee absolute safety. Also, I understand that I share the responsibility for safety during any Adventure, and I assume that responsibility. I will make my instructors aware to the best of my ability of any questions or concerns regarding my understanding of safety standards, guidelines, procedures and my ability to participate at any point during any Adventure*

I understand
Understand that risks during an Adventure include but are not limited to loss damage to personal property, injury, permanent disability, fatality, exposure to inclement weather, slipping, falling, insect or animal bites, being struck by falling objects, equipment failure, tripping, falling, immersion in cold water, hypothermia (cold exposure), hyperthermia (heat exposure), attack, and severe social or economic losses that may result from such incident. I also understand that such accidents or illnesses may occur in remote areas without easy access to medical facilities or while travelling to and from Adventure sites. Further, there may be risks not known to me or not reasonably foreseeable at this time*

I understand
I agree
I agree
I agree

Release of Liability, Waiver of Claims, and Indemnifying Release to Qi Creative Inc. Agreement
I understand
I understand
I understand
I understand
I understand
Signature*

Photo and Video Release Form

Qi Creative Inc.
YesNo
I hereby grant to Qi Creative Inc., its subsidiaries, licensees, successors and assigns, the right to use, publish, and reproduce, for all purposes, my and/or my child's name and pictures of me in film or electronic (video) form, sound and video recordings of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media including, without limitation, cable and broadcast television and the Internet, and for exhibition, distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences and in brochures and other print media. This permission extends to all languages, media, formats and markets now known or hereafter devised. This permission shall continue forever unless I revoke the permission in writing.

I further grant Qi Creative Inc. all right, title, and interest that I may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grant Qi Creative Inc. the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for marketing, communications, or advertising purposes, as it deems fit.

I hereby waive the right to receive any payment for signing this release and waive the right to receive any payment for Qi Creative Inc.’s use of any of the material described above for any of the purposes authorized by this release. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer generated scanned image and other electronic media that may be used in conjunction wherewith or to approve the eventual use that it might be applied.

I acknowledge that Qi Creative Inc. will collect, use, and disclose my personal information in accordance with Alberta's Access to Information Act (ATIA) and Privacy Act (PA), and I consent to such handling of my information as required under these laws.
Name of Child Participant:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Name of Right Giver/Guardian or Participant*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Right Giver/Guardian*
Should be Empty:

Qi AC Membership Form

Emergency Contact Information

Health & Wellness

Communication

Participant Member Code of Conduct

Assumption of Risk

Release of Liability, Waiver of Claims, and Indemnifying Release to Qi Creative Inc. Agreement

Photo and Video Release Form