Home Canoe Tasmania Slalom Squad 2017 Rego Form

Participants/Child's Name (required)

Participants Address (required)

Date of birth: dd/mm/yyyy (required)

Parent email contact (required)

Phone (required)

Emergency Contact: Name

Emergency Contact No: (required)

Medical Questionnaire and Consent (required)
Does your child suffer from any medical condition illness injury or disability that may interfere with or be aggravated by the proposed activity?
If yes please provide details
Is the above mentioned condition likely to require any special attention, treatment or medication
during the activity? (required)
If yes please provide details
Has you/your child ever had a serious allergic reaction to an insect, animal or plant? (required)
If yes please provide details (including reaction & treatment):
Can you/your child swim 25 metres?

Indemnity Agreement & Waiver of Liability: (required) I / we hereby acknowledge and understand that I / my son / my daughter / my dependent mentioned above will be participating in a Canoe Tasmania Canoe Education event, and that I fully understand the nature of the activity to be undertaken after having read and understood any printed material supplied to me and after making enquiries to my satisfaction.
In consideration of the Canoe Tasmania Inc. providing this activity for me / my daughter / my son / my dependent I
hereby acknowledge that Canoe Tasmania Inc. and Australian Canoeing Inc., their Instructors, employees, officers,
servants and agents shall not be liable for any injury, damage, loss, claim or demand whatsoever which may arise
during, or in association with, participation in or travelling to or from the activity unless the same is caused by
negligence or a criminal act on the part of the said Canoe Tasmania Inc. or Australian Canoeing Inc., their
Instructors, employees, officers, servants and agents and I / we hereby agree to indemnify and keep indemnified
the said Canoe Tasmania Inc, Australian Canoeing Inc., their Instructors, employees, officers, servants and agents
against all actions, suits, damage claims and demands arising out of any accident, loss or illness which may befall
me / my son / my daughter / my dependent during or as a result of my / his / her participation In any activity or
function connected with the event or whilst travelling to or from the said event unless the same is caused by
negligence or a criminal act on the part of the said Canoe Tasmania Inc. or Australian Canoeing Inc., their
Instructors, employees, officers, servants and agents. If you agree please check box.YesNo

Consent For Emergency Transport &/Or Medical Attention (required): I hereby give consent for me/my daughter/my son/my dependent, mentioned above to being transported by Ambulance or other appropriate transport to the nearest medical centre or hospital for emergency or life preserving treatment by an appropriately qualified medical person. If you agree please check box. YesNo

Your Name

Payment: (to be made prior to commencement)

Costs:
CLUB MEMBERSHIP $25-$60 Already a club member

COACHING $150
For second child or siblings in one family; coaching = $75

Total Amount Paid: $

Transaction Receipt Number:

Cancelation Fees apply: cancellation 21 days or more prior to course full refund
20-14 days prior to course 10% of course fee
13-2 days prior to course 15% of course fee
less than 48 hours no refund.

Any further information