CCC Paddler Info

Canoe Club Registration Form
Paddler's Name*
First NameLast Name
Paddler's Birth Date*
MonthDayYear
Gender*
MaleFemale
Shirt Size: From time to time we may order racing or other shirts for our padders. Sizing helps us plan.*
X-SmallSmallMediumLargeI already have a Team shirt
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Paddler's Email (Parent email will be in next section)
example@example.com
Parent/Guardian Information
Name
First NameLast Name
Phone Number
Parent / Guardian E-mail
example@example.com
Emergency Information
Emergency Contact's Name*
First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Health/Medical Conditions
HeadachesHeart diseaseEpilepsyAsthmaDiabetesFaintingBehaviour IssuesHerniaJoint InjuryBroken BonesBack ProblemsPneumoniaBronchitisAllergiesSkin diseaseRheumatic FeverInner Ear IssuesADD/ADHDTuberculosisGlasses/ContactsOther
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
Does the athlete have any other allergies, chronic illness, or medical conditions? If yes, please describe.
Doctor's Name
First NameLast Name
Doctor's Phone
WAIVER OF LIABILITY AND RELEASE OF CLAIMS
WAIVER OF LIABILITY AND RELEASE OF CLAIMS
In consideration of being allowed to participate in the activities organized by [Canoe Club Name], I, the undersigned, hereby acknowledge and agree to the following terms and conditions:
Assumption of Risks: I understand that participating in canoeing and related activities involves inherent risks, including but not limited to the risk of injury, drowning, and property damage. I voluntarily assume all such risks and acknowledge that they are an inherent part of the activity.
Physical Condition: I certify that I am in good physical condition and have no medical conditions that would prevent my safe participation in canoeing activities. I agree to inform [Canoe Club Name] of any changes in my health that may affect my ability to participate.
Rules and Guidelines: I agree to abide by all rules, guidelines, and safety instructions provided by [Canoe Club Name] and its representatives. I understand that failure to comply with these rules may result in my removal from the activity.
Waiver of Liability: I hereby waive, release, and discharge [Canoe Club Name], its officers, directors, instructors, volunteers, and any other representatives from any and all claims, liabilities, demands, actions, or causes of action that may arise out of or are in any way connected with my participation in canoeing activities.
Indemnification: I agree to indemnify and hold harmless [Canoe Club Name], its officers, directors, instructors, volunteers, and any other representatives from any and all claims brought by me or a third party arising out of my participation in canoeing activities.
Emergency Medical Treatment: In the event of an injury or medical emergency, I authorize [Canoe Club Name] and its representatives to seek and consent to emergency medical treatment on my behalf.
Photographic Release: I grant [Canoe Club Name] permission to use photographs or videos of me taken during canoeing activities for promotional or educational purposes without compensation.
Medical Release and Authorization
In the event of a medical emergency or injury during my participation in activities organized by [Canoe Club Name], I, the undersigned, authorize and consent to the provision of necessary medical treatment for myself or my minor child.
Authorization for Medical Treatment:
I hereby authorize [Canoe Club Name], its representatives, and any medical professionals engaged by them to provide, seek, and consent to emergency medical treatment, including but not limited to first aid, CPR, administration of medication, and any other necessary medical interventions.
Medical Facility Authorization:
In the event that immediate medical attention is required, I authorize [Canoe Club Name] and its representatives to transport me/my child to the nearest medical facility for treatment.
Release of Information:
I authorize the release of relevant medical information to medical professionals and emergency personnel for the purpose of administering proper medical treatment.
Insurance Information:
I understand that [Canoe Club Name] does not provide medical insurance coverage. I certify that I have personal health insurance coverage to cover any medical expenses that may be incurred.
I agree to the Medical Release statement
I give permissionI do not give permission
Consent and Release of Information
I, the undersigned, hereby grant permission to [Canoe Club Name] to use and release certain information and media for promotional and educational purposes related to my participation in canoeing activities.

Consent for Use of Media:
I hereby grant [Canoe Club Name] the irrevocable and unrestricted right to use, reproduce, and publish photographs, videos, or other media in which I may be included, for promotional and educational purposes. This includes, but is not limited to, website content, social media, promotional materials, and educational presentations.
Release of Information:
I authorize the release of my name, age, and general information related to my participation in canoeing activities for promotional and educational purposes.
Duration of Consent:
This consent and release of information remain valid indefinitely, unless I provide written revocation to [Canoe Club Name].
Revocation of Consent:
I understand that I may revoke this consent at any time by providing written notice to [Canoe Club Name]. However, revocation does not affect any actions taken by [Canoe Club Name] before receiving such notice.
No Compensation:
I understand that I will not receive any compensation for the use of the information and media described in this consent.
Signature*
Clear
Signatures Name*
First NameLast Name
Should be Empty:

Canoe Club Registration Form