Qi AC: Membership Form

Qi AC Membership Form

Qi Creative Inc. • Qi Adventure Club
What Qi Adventures are you interested in?*

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.
Participant's Birthdate:*

MonthDayYear
Date
Participant's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the participant covered by Medical Insurance?*

YesNo
Please provide the participant's Insurance Information:*
Insurance Company, Policy/Certificate #
Is the participant is a minor or under guardianship?*

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.
Emergency Contact Secondary Phone Number:
Please enter a valid phone number.
Emergency Contact Email:*
example@example.com
Emergency Contact Relationship to Participant:*

Communication
I give permission to Qi Creative staff and volunteers to record video or take photographs of the during Qi Adventure Club programs in order to collect and analyze data. I understand that this documentation may be used for workshops, presentations, and/or commercial use (website, social media).*

YesNo
I give permission to Qi Creative staff and volunteers to request/release information concerning mine and/or the participant's communication, learning abilities, and accommodations from/to any relevant agencies.*

YesNo
I understand that the information submitted to this form was provided freely and is protected in accordance with the Access to Information Act and Protection of Privacy Act. I also understand that I can withdraw my consent by notifying Qi Creative in writing.*

I understand
I agree to participate in the Qi Adventure Club and follow the Qi Adventure Club Participant Code of Conduct (see next page). I also affirm that all information required was fully disclosed in this entire registration form without omission.*

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 have read and understand the Participant's Code of Conduct and will practice respect to the best of my ability. I also understand that if I fail to follow the code of conduct, I may not be permitted to participate.

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
Agree that prior to participation, I will inspect, to the best of my ability, the facilities and equipment to be used. If I believe anything is unsafe, I will immediately advise the Qi staff, volunteers, and site specific agents present of such condition and refuse to participate*

I agree
Agree that I will refrain from the consumption of alcohol, cannabis, and/or illegal drugs while participating in a Qi Adventure*

I agree
Agree to conduct my behaviour in accordance with the Qi Adventure Club's Participant Code of Conduct and site specific rules, regulations, codes, and laws.*

I agree

Release of Liability, Waiver of Claims, and Indemnifying Release to Qi Creative Inc. Agreement
Understand that this ASSUMPTION OF RISK AGREEMENT, RELEASE OF LIABILITY, WAIVER OF CLAIMS, AND INDEMNIFYING RELEASE TO QI CREATIVE INC AGREEMENT is binding on myself, my heirs, next of kin, my executors, administrators, personal representatives and assigns*

I understand
WAIVE ANY AND ALL CLAIMS that I have, or may in the future have, against Qi Creative Incorporated, their directors, officers, employees, contractors, sponsors, partners, agents and representatives (all of whom are hereinafter collectively referred to as 'the Releasees’)*

I understand
TO RELEASE THE RELEASEES from any and all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my participation in an Adventure due to any cause whatsoever, INCLUDING NEGLIGENCE ON THE PART OF THE RELEASEES*

I understand
TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damages of any kind, damage to property of, loss of property of, or personal injury to, any third party, resulting from my participation in an Adventure.*

I understand
I HAVE READ AND UNDERSTOOD THIS AGREEMENT, and I am aware that by signing this agreement I am WAIVING CERTAIN LEGAL RIGHTS which I or my heirs, next of kin, executors, administrators, personal representatives and assignees may have against the releasees.*

I understand
Signature*

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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