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Registration / Medical / Skills Form & Hold Harmless Agreement
2064423 Ontario Inc owner / operator of 1060848 Ontario Inc O/A
TrainingZone.ca (canoe-ontario.ca, SARTA, code-one.ca) & La Cloche Mountain Institute
Participants Name:______________________________Birth Date: _____/____/____ Health Card#: _________________________
Parent / Guardian Name:______________________________________ Street:___________________________________________
City:____________________________________________ Province:______________________Postal Code:__________________
Phone: (_____)___________________Participants Cell:(_____)___________________ Parents Cell: (_____)__________________
Medications ________________________________________________________________________________ Food ________________________________________________________________________________ Plants ________________________________________________________________________________ Animals ________________________________________________________________________________ Insect Bites ________________________________________________________________________________ Other:_______________________________________________________________________________________
Asthma _____________________________________________________________________________ Diabetes _____________________________________________________________________________ Heart Disease _____________________________________________________________________________ Convulsions _____________________________________________________________________________ Infectious Disease _____________________________________________________________________________ Other:_______________________________________________________________________________________
Ventolin ________________________________________________________________________________ Epi-pen ________________________________________________________________________________ Anti-seizure ________________________________________________________________________________ Insulin ________________________________________________________________________________ Special Diet ________________________________________________________________________________ Other ________________________________________________________________________________________ All Immunizations (If no, explain in concerns)
Please List your Physical Limitations / Concerns: ____________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ There are inherent risks involved with participating in the proposed activities and courses. 1060848 Ontario Inc provides Instructor, Consultant, Advisor and Guide Services only and does not provide the activities nor act in a guardian capacity. Every effort is made to guide the participants in choosing safe actions. The participants as a group conceive and implement their activities and are responsible for their own actions and safety. All participants must provide and use the appropriate equipment / safety equipment for each activity. Equipment borrowed from 1060848 Ontario Inc is at the participants risk. Each participant is responsible for inspection for wear and tear, improper maintenance or storage and mechanical defects of all equipment prior to use and is responsible for all damages or losses thereof and assumes all risk associated with using said equipment. All participants must be of good physical condition, able to swim while wearing a PFD, and able to carry 15 to 35 kg (30 to 75 lbs) for 0.5 to 2 km (0.25 to 1.5 miles). It is the participant’s duty to inform us of equipment defects, any restrictions, any medical problems and their level of skill (Please complete medical / skills form above) so that the appropriate education or guidance can be given. I, ______________________________________(Print name) have read and understood the statement above and have completed the medical / skills questionnaire. I understand that participation in these activities, using the skills that are learned by participating in said activities and using said equipment involves a certain degree of risk that could result in injury, death or loss or damage to person or property. After carefully considering the risk involved and my personal health, knowledge and capabilities, I knowingly and freely assume all such risks. I agree, for myself and on behalf of my heirs, assigns and next of kin, to hold-harmless and waive all claims associated with these activities, use of equipment or use of learned skills which I may have against 1060848 Ontario Inc. (o/a TrainingZone.ca - canoe-ontario.ca, code-one.ca, SARTA), or La Cloche Mountain Institute, La Cloche Mountain Institute Trust including each of; their owners, directors, officers, employees, volunteers, other participants or trustees. _______________________________________________________________________________________________________________/_____/_____ Signature (Participant) (yyyy / mm / dd) I, ______________________________________ as Parent / Guardian of this participant, have been advised that I should join and supervise all said activities at my own risk and expense so as to act as guardian of my ward or child. By not attending said activities, I am stating that my Ward or Child has the capacity to act on their own behalf to carefully consider the risk involved and their personal capabilities and to knowingly and freely assume all such risks. I consent and agree to his / her release as provided above, for myself and on behalf of my heirs, assigns and next of kin, from any and all liabilities incident to my minor child’s involvement in said activities. ________________________________________________________________________ ________________________________________/_____/_____ Signature (Parent / Guardian) (yyyy / mm / dd)
98 Main St, Webbwood, Ont. Phone 705-805-0605
The Breast (2001) 10, 15–19# 2001 Harcourt Publishers Ltddoi:10.1054/brst.2000.0176, available online at http://www.idealibrary.com onApplied kinesiology for treatment of women with mastalgiaW. M. Gregory,1 S. P. Mills,2 H. H. Hamed1 and I. S. Fentiman11Hedley Atkins Breast Unit, Guy’s Hospital, London, UK; 2Association of Systematic Kinesiology, Surbiton,Surrey, UKS U M M A R Y. To deter
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