The Northwest Passage Waiver Form

What experience have you had with this activity? *

Can you swim? (For water-based outings)*

YesNo

This is our current COVID-19 Response Plan (we reserve the right to change or adapt this plan as additional information becomes available): Each participant must verify that they have not experienced any symptoms of COVID-19 within 14 days of the start of the program. If they have, they will not be allowed to participate in any activity unless they provide the results of a recent COVID-19 test verifying that they are currently not infected. If a participant tests positive for COVID-19 within 14 days of the beginning or end of the program they must notify The Northwest Passage immediately so we may take appropriate actions including notifying other participants who may have been exposed to the virus.

Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?*

YesNo

Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?*

YesNo

Do you have any Medical Conditions? *

Do you have allergies?*

YesNo

If yes please describe below.

Please list and describe any medications you are currently taking. *

Do you have any dietary restictions? *

Person to be contacted in case of emergency:*

First NameLast Name

What is your relationship to this person?*

Phone for emergency contact*

Area CodePhone Number

Alternate phone for emergency contact

Area CodePhone Number

To print a copy of this waiver click "Print Form" (located at the very bottom of this form)

Name of your outing(s):*

In consideration of being allowed to participate in any way on the trips(s) listed above and any related events and activities, I the undersigned, acknowledge, appreciate, and willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. I understand that in joining this The Northwest Passage Outing Club, Inc., (hereafter “NWP” Outing, I will be faced with certain inherent risks and exposures to danger in geographic areas which may be remote from facilities where medical treatment can be obtained. I, the undersigned, acknowledge, appreciate and agree that the risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death. Such hazards may include, but are not limited to: falling, slipping, drowning, your physical coordination, ability to operate equipment, ability to swim, fatigue, capsize, falling objects, collision, crashing or otherwise causing bodily harm, upset, striking obstructions or other persons, unsafe speed of travel for conditions or experience, equipment failure, inadequate or improper instruction or assistance, failure to wear protective clothing, elevation changes, weather conditions including electrical storms, lightning, variances and extremes of wind, exposure to wild animals and insects, the collapse of natural or man-made structures, potable water contamination, temperature exposure (hypothermia, frostbite, frostnip, sunburn, snow blindness, sun stroke, dehydration), altitude sickness, inadequate or improper skills and experience of participants and guides. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasee’s or others, and assume full responsibility for my participation.

I, for myself and on the behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless The Northwest Passage Outing Club, Inc., its officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (release’s), from any and all claims, demands, losses, and liability arising out of or related to any injury, disability or death I may suffer, or loss or damage to person or property, whether arising from the negligence of the release’s or otherwise, to the fullest extent permitted by law. Should I be injured on this Outing I understand that various expenses may be incurred in rendering rescue operations and medical care, and I agree that I will be responsible for any such costs of evacuation procedures, rescue operations, and emergency or non-emergency medical services which may be occasioned by my participation in the Outing.

In making an application to participate in the Outing, I affirm that I am in good health, capable of performing the required exercise to participate and that I accept, at my personal risk, the hazards of such participation in the Outing and will not hold NWP, its members, other participants or its representatives responsible. In consideration of NWP accepting my application, I hereby release and forever discharge NWP, its officers, directors, servants, employees and agents and the other participants from any liability whatsoever arising as a result of my participation in the Outing. This release is binding upon me, my heirs, executors, administrators, and assigns.

I understand that by joining this program and with the related travel I may be exposed to communicable diseases (e.g.COVID-19). I understand that The Northwest Passage cannot protect me from exposure and that despite their best efforts I may be increasing my risk of exposure and infection by joining this program.

I have read this Release of Liability and Assumption of Risk Agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.

Waiver & Release of Liability Signature*

Participant Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of signing*

Date

Are you signing this waiver for a minor?*

YesNo

FOR PARENTS/GUARDIANS OF PARTICIPANT OF MINOR AGE (UNDER AGE 18 AT TIME OF REGISTRATION)

This is to clarify that I, as a parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Release’s from any and all liability incidents to my minor child’s involvement or participation in these programs as provided above, even if arising from negligence of the Release’s, to the fullest extent permitted by law.

Parent name:

First NameLast Name

Minor name

First NameLast Name

Date of signing

Date

Signature

The Northwest Passage Fact Sheet and Waiver Form

Waiver, Release of Liability, and Assumption of Risk Agreement