Loading...

READ CAREFULLY

Waiver of Release of Liability

     In consideration of The Kayak Centre at Wickford Cove, LLC furnishing services and/or equipment for me to participate in outdoor activities, programs, expeditions, and/or courses planned or supervised by The Kayak Centre, LLC I agree as follows.

     I fully understand that outdoor activities have: (a) inherent risks, dangers, and hazards and such exists in my use of The Kayak Centre equipment and my participation in outdoor activities, programs, expeditions and/or courses planned and supervised by The Kayak Centre; (b) my participation in such activities and/or use of such equipment may result in injury or illness including but not limiting to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other aliment that could cause serious disability; (c) these risks and dangers may be caused by the negligence of the owners, employees, officers, or agents of The Kayak Centre; the negligence of the participant, the negligence of others, accidents, breaches of contract, the forces of nature, or the causes.  Risks or dangers may arise from foreseeable or unforeseeable causes including, but not limiting to, guide decision making, including that the guide may misjudge terrain, weather, trail or river route location, and water level, risks of falling out of or drowning while in a raft, canoe, or kayak and such other risks, hazards and dangers that are integral to recreational activities that take place in a wilderness, outdoor or recreational environment; and (d) by my participation in these activities and for use of equipment I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or other conduct of the owners, agents, officers, or employees of The Kayak Centre, or by any other person.

     I, on behalf of myself, me personal representatives and my heirs hereby voluntarily agree to release, waive, discharge, hold harmless, defend and indemnify The Kayak Centre and its owners, agents, officers, and employees from any and all claims, actions, or losses for bodily injury, property damage, wrongful death, loss of services, or otherwise which may arise out of misuse of the Kayak Centre equipment or my participation in kayaking activities. I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for negligent acts or other conduct by the owners, agents, officers or employees of the Kayak Centre.

    I do further authorize The Kayak Centre, to photograph, televise, videotape or by any other means, record the image or voice of the participant while engaged in any activity planned or promoted by The Kayak Centre, and to use such records for instructional, promotional, or commercial use.

I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT AGREE. IT IS MY INTENTION TO EXEMPT AND RELIEVE THE KAYAK CENTRE AT WICKFORD COVE, LLC FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.

Dated: February 18, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Medical History Questionnaire


Event Title:

Date of Event: *

Do you presently have, or have you ever had any of the following?

Diabetes*
No
Yes
Heart Disease*
No
Yes
Asthma*
No
Yes
Epilepsy*
No
Yes
High/Low Blood Pressure*
No
Yes
Shoulder Dislocation/Subluxation*
No
Yes
Allergies (bee sting, food, etc)*
No
Yes

If yes to any of the above, do you carry medication? What type?

(If YES to BEE STING, please make sure you bring your own bee sting kit!)

Do you wear contact lenses?*
No
Yes
Has your physical activity been restricted or altered during the past five years?*
No
Yes

If yes, why?
Have you had a recent significant illness or injury or been hospitalized other than already noted?*
No
Yes

If yes, please explain.
Are you presently on any medication other than already noted?*
No
Yes

If so, what?
Do you have any medical problems that might exclude you from participation in vigorous physical activity?*
No
Yes

If so, what?
Please rate your swimming ability:*

Is there anything else you need us to know about before you get on the water?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver