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Participant Waiver for Kayak Program

The Region X Pty Ltd

 

I / we acknowledge that I / we have voluntarily applied to participate in the experience provided by Region X.

I / we are voluntarily participating in the experience with the knowledge that the travel to areas visited may involve risks and dangers including, but not limited to;

  • Bodily exertion to which I / we may not be accustomed
  • The hazards of travelling in the outdoors during extremes of weather and temperature including sudden and unexpected change
  • The possibility of accident remote from normal medical services and difficulties of evacuation
  • The risks of travelling in the outdoors including slippery, uneven and unstable surfaces, stings, bites, navigating ocean, bay or estuary waters, collision with my own or other vehicles

I am also prepared for any pre existing medical conditions, allergies and reactions i / we / our group have. I acknowledge that for safety reasons I must wear a Personal floatation device while kayaking at all times.

I understand this experience is guided and i follow directions from Region X team. 

I / we hereby agree to be responsible for my / our own welfare, accept any and all risks of unanticipated events, illness, injury and emotional trauma. I accept that my photograph may be taken and used in promotional material including flyers and websites.

I hereby release and discharge Region X Pty Ltd, its subsidiaries, agents, employees from and against all liability arising from my participation in this activity.

I / We have carefully read and fully understand the contents of this agreement and the booking conditions. I understand that this is a legally binding and enforceable contract and sign it of my own free will. 


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Special requirements

Medical conditions (EG asthma, diabetes etc)

Medications carried in case of emergency

Physical injury or major operations that may effect your participation

Dietary requirements
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 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.


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