TO: THE UNIVERSITY OF WINNIPEG, as represented by WII CHIIWAAKANAK LEARNING CENTRE (“University”)
RE: COMMUNITY PROGRAM (“Program”)
INFORMED CONSENT, RISK ACKNOWLEDGEMENT AND INDEMNITY AGREEMENT
WARNING: By signing this document you indicate that you understand the risks associated with the Program, that you are aware that by allowing your child to participate in the Program on Campus, you are exposing him/her/them to the risks identified below. It gives the University authority to secure medical assistance for your child for which you agree to be financially responsible. You are agreeing to assume financial responsibility for any legal costs, payments or judgments made in favour of your child, as well as any damages to third persons or their property caused by your child.
PLEASE READ CAREFULLY!
Participation in the Program, carries certain inherent risks. I am aware that by allowing my child to participate in the Program, my child may be exposed to any manner of harm, injury, illness, death or property damage resulting from such risks, including but not limited to the following:
General Risks:
Loss or damage of personal property by any means including, but not limited to, theft, vandalism, fire, or water damage;
Travel by walking, motor vehicle, bus or any other means of transportation to, from, or during the Program; Food Consumption: ensure your child is aware not to partake of drinks/food that may be provided during this Program if they have any food allergies; and
Loss, damage, injury, illness, death or expense that my child may, or that members of my child’s household(s) may suffer, including the contraction of a Communicable Disease as a result of my child’s participation in the Program. Communicable Diseases include, but are not limited to, any disease that can be transmitted from one person to another including viruses, bacteria, parasites or other organisms.
NOTE: Please consult with your child’s physician prior to them participating in any physical activity(ies) or using any equipment if they have any pre-existing conditions which may be affected by their participation in the activity(ies).
Activity(ies) Risks:
All manner of physical and neurological injuries;
Contact with participants or other people or sustaining injuries arising from their actions;
My child’s participation and/or use of equipment/materials beyond their own skills and abilities; and
The use, misuse, failure or malfunctioning of equipment/materials.
I have explained the risks associated with this activity to my child and he/she/they understand(s) the risks.
In consideration of the University allowing my child to participate in the Program, I agree as follows:
The University may administer first aid treatment to my child and may secure such medical advice and services as the University, in its sole discretion, may deem necessary for my child’s health and safety and I shall be financially responsible for such medical advice and services;
If circumstances arise in which the University, in its sole discretion, considers to be an emergency, I authorize the University to disclose any of my child’s personal medical, health or contact information, as the University deems reasonable;
I understand that it is my child’s responsibility to abide by the rules and regulations imposed on the participants by the University / Wii Chiiwaakanak Learning Centre and its Instructors and Volunteers. I have explained to my child the need to follow the instructions given by the Instructors and Volunteers;
I agree to HOLD HARMLESS AND INDEMNIFY the University, its Board of Regents, officers, employees, students, agents, representatives, members, volunteers and independent contractors, from any and all liability for the following:
any legal costs or payments made pursuant to a settlement or trial judgment in favour of my child and in relation to my child’s participation in the Program; and
any damages to the property of, or personal injury to, any third party, resulting from my child’s participation in the Program.
I agree that this Agreement shall be governed by and construed in accordance with the laws in force in the province of Manitoba and the federal laws of Canada, as applicable, and that the courts of Manitoba shall have exclusive jurisdiction over all claims, disputes and actions arising out of or related to my child’s participation in the Program, and this Agreement.
In entering into this Agreement, I confirm that I am not relying upon any oral or written representations or statements made by the University other than what is set forth in this Agreement.
I consent to my child’s personal information being collected under The University of Winnipeg Act (Manitoba) and 36(1)(b) of The Freedom of Information and Protection of Privacy Act (Manitoba) for the purposes set out herein. I understand that I may contact the University’s Wii Chiiwaakanak Learning Centre, 511 Ellice Ave, Winnipeg, MB, R3B 2E9, wiichii@uwinnipeg.ca, or to 204.258.2951 with any questions regarding privacy.
I CERTIFY THAT I AM THE PARENT AND/OR LEGAL GUARDIAN OF MY CHILD.
I CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND THAT I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM ACCEPTING FINANCIAL RESPONSIBILITY FOR ANY MEDICAL ASSISTANCE THE UNIVERSITY MAY DEEM NECESSARY FOR MY CHILD’S HEALTH AND SAFETY, FOR ANY LEGAL COSTS, PAYMENTS OR JUDGMENTS MADE IN FAVOUR OF MY CHILD AND FOR DAMAGE TO THIRD PERSONS OR THEIR PROPERTY THAT MY CHILD MAY CAUSE.