Survivor Thrivers Membership Form 2021-2022

1
Please choose one of four options from the drop down menu.* This field is required.
Survivor Competitive Paddler $150
Supporter Competitive Paddler $150
Dusty Dragon Non-competitive Paddler $75
Survivor or Supporter Non-paddler $50
Alumni
2
Name* This field is required.
Last Name, First Name
3
Email
example@example.com
4
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
ON
Province
Postal Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth
Day/Month/Year
6
Primary Phone Number * This field is required.
Area code and phone number.
7
Secondary Phone Number
Area code and phone number.
8
Emergency Contact Information
Emergency Name
Please enter your emergency contact's phone number
9
Doctor's Contact Information
Doctor's Name
Please enter your doctor's phone
10
Medical InformationPlease complete any pertinent medical information as listed below:
Medical Conditionas
Allergies
Medications
11
Please check one on each of the 5 rows (slider on right)* This field is required.
Yes
No
Maybe
Not Applicable
Publish Photo?
First Aid"
CPR?
Interested in Steering?
Interested in Drumming?
Publish Photo?
First Aid"
CPR?
Interested in Steering?
Interested in Drumming?
Yes
No
Maybe
Not Applicable
Yes
No
Maybe
Not Applicable
Yes
No
Maybe
Not Applicable
Yes
No
Maybe
Not Applicable
Yes
No
Maybe
Not Applicable
1 of 5
12
Able to swim 50 metres?* This field is required.
Yes, no problem
With difficulty
Not at all
Not Applicable
Yes, no problem
With difficulty
Not at all
Not Applicable
13
Paddling side?* This field is required.
Left
Right
No Preference
Not Applicable
Left
Right
No Preference
Not Applicable
14
Needed to balance the boat.* This field is required.
Height in ft/in.
Weight in lbs.
15
Committment of Members* This field is required. Committment for Competitive Paddlers As a member of the team we all need to do our part in helping the team to continue to be successful. Members are expected to contribute in the following ways: Special Events-Boat Maintenance-Fundraising-Support Group-Candlelight Walk-Committees- Bingos(3 per session)-Yard Sales, etc. Committment to Fitness for Competitive Paddlers I understand that I am part of a team: I have responsibilities to my team mates and will contribute to a positive environment on the boat. I recognize that fitness is a year-long, lifetime committment. I will continue my fitness regimen during the winter months as wall as during the paddling season.
YESNO
16
SurvivorThrivers Waiver of Liability, Indemnification and Release of Liability 2021-2022* This field is required. Please be sure to read to bottom of the page. In consideration for receiving permission to participate in the Survivor Thrivers – Breast Cancer Survivors Society (herein referred to as the ‘Survivor Thrivers’) as well as join in practice sessions and enter the premises, waterways and ground supervised or in any way controlled by the Survivor Thrivers, the receipt and said permission being hereby acknowledged. I hereby forever release any and all liability, discharge and agree not to sue the Survivor Thrivers, their respective directors, members, trustees, agents, representative, officers, sponsors, licensors, volunteers and employees and agree to save them harmless and indemnify them from and against any and all liability claims, injuries, losses, damages, expenses, demands, actions and causes of action of whatsoever kind or nature arising out of or related to any such loss or damage or injury, including death etc. that may be sustained by myself for whatever reason while participating within the bounds of the Survivor Thrivers activities including practice sessions, travelling to and from and while participating in festivals and any other activities and any ground supervised or controlled by the Survivor Thrivers. I also agree to and discharge forthwith on request of the Survivor Thrivers and their respective directors, agents, members, trustees, representatives, officers, sponsors, licensors, volunteers and employees and their authorized representatives each and every obligation or claim which shall be made, assigned or appointed against the Survivor Thrivers and its aforesaid members etc. by any party by virtue of injury or damage caused by myself or to myself absolutely. I and my next of kin are duly aware of the risks and hazards inherent in both the sport of dragon boating and entering the premises used for any purpose connected with the activities of the Survivor Thrivers including festivals, regattas and practice sessions. I also give notice that I voluntarily assume any risks of loss, damage, or injury including death that may be sustained by me or any property while in or upon said premises or engaged in any said event or practice. I agree that use of a Personal Flotation Device is mandatory while in the boat and agree to wear proper safety equipment as supplied by Survivor Thrivers or myself at all times. In signing this release, I herby acknowledge and represent that I have read, understood and agree to it voluntarily, that I am 18 years of age or older. (Less than 18 years of age requires cosignature of a parent or guardian as applicable)
YESNO
17
I have read and agree with the above Committment for Competitive Paddlers and /or Waiver of Liability, Indemnification and Release of Liability* This field is required.
YESNO
18
Date* This field is required.
Date
Year
Month
Day
19
Signature
Clear
Should be Empty:

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