Rise Up Youth Council

1

Participant Name

First Name

Last Name

2

Phone Number

Please enter a valid phone number.

3

Birth Date

4

Ancestry (*Ancestry stats are collected for the purpose of funders)

Status

Non-Status

Metis

Inuit

5

Allergies/Medical conditions

6

Parent / Guardian Name*** if youth under 18 years old

First Name

Last Name

7

Parent/ Guardian Cell Number**if youth under 18

8

Parent/Guardian Email**if youth under 18

9

Alt. Phone NumberAlternate Emergency Contact Phone Number

10

Any Other Information

11

Informed Consent and Acknowledgement

18 or older

I hereby agree to participate in activities offered by Rise Up Indigenous Wellness during the selected activity or program. In consideration of my participation, I understand and assume the risks and hazards that may be associated with these activities and release, absolve and hold harmless Rise Up Indigenous Wellness, its officers, employees, facilitators, agents and representatives from liability for injuries arising from travelling to, participating in, or returning from the selected activities or program.

In the event of injury, I waive claims against Rise Up Indigenous Wellness, including its facilitators, affiliates, participants, sponsoring agencies and, where applicable, owners or lessors of premises used for the activity. I understand that participation in recreational, sport and land-based activities involves inherent risks of injury, which may vary depending on the activity. By signing below, I confirm that I understand these risks and voluntarily choose to participate.

Parents/Guardians of youth under 18

Parents/ Guardians must read, agree and sign.

I hereby give my approval for my child’s participation in any and all activities prepared by Rise Up Indigenous Wellness during the selected activity. In exchange for the acceptance of said child’s candidacy by Rise Up Indigenous Wellness, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Rise Up Indigenous Wellness and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Rise Up Indigenous Wellness including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

12

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

13

Date

14

Signature