Last updated 5-Dec-07

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COUREURS de BOIS CLUB OTTAWA INC. --- Membership Form

PART A - WAIVER OF LIABILITY

In consideration of my membership in the Coureurs de Bois Club Ottawa Inc., I,________________________,hereby agree as follows:

1. that I fully understand that the Coureurs de Bois Club Ottawa Inc. is a democratic, non-profit organization of equals engaged in canoeing, kayaking, hiking, skiing, and other outdoor activities for the mutual benefit of all participants;

2. that, accordingly, I understand that the Coureurs de Bois Club Ottawa Inc. does not lead, nor contract to take myself, nor any other person, on trips;

3. that I recognize the risks involved with river trips and outdoor activities, including the risks of capsize, collision, drowning, injury to body and damage or loss of equipment;

4. that, in addition to the acknowledgments of such risks, I agree that I will not, in any way, hold the trip organizers, other participants, members, executive or directors of the Coureurs de Bois Club Ottawa Inc. liable for any claims or demands for damages or injuries or losses of any nature or kind to me or my property, however caused, which I, my successors, executors, heirs or assigns have, or may in the future have, by reason of, or in any way arising out of my participation in Coureurs de Bois Club Ottawa Inc. activities;

5. that I agree to pay the cost of any emergency evacuation of my person and belongings that may become necessary by reason of or in any way arising out of my participation in Coureurs de Bois Ottawa Club Inc. activities;

6. that I further acknowledge that any medical conditions or physical disabilities as set out in my Medical Disclosure Form, attached hereto, constitute full and absolute disclosure of same and that there are no other medical reasons that would not allow me to participate fully and safely in any activities of the Coureurs de Bois Club Ottawa Inc. or which may jeopardize or bring risk to the safety or health of other participants in such activities or their equipment;

7. that I undertake to disclose the contents of my Medical Disclosure Form, attached hereto, to the apparent organizer of any Coureurs de Bois Club Ottawa Inc. activity in which I participate insofar as such contents are reasonably relevant to the particular activity; and

8. that as a parent or guardian of a child under 18 years of age, I will accompany and responsibly supervise that child while they are engaged in a Coureurs de Bois Club Ottawa Inc. activity, and will accept responsibility for them.;

9. that I acknowledge that I have read the above and fully understand the nature and consequences of granting my consent and waiving any and all claims for liability of damages against the trip organizers, other participants, members, executive or directors of the Coureurs de Bois Club Ottawa Inc.

Dated at _____________ the ______ day of ____________, 200__

Signed: _____________________ Witness:* __________________

*Signature of parent or guardian required if under 18 years of age.

PART B - MEDICAL DISCLOSURE

I. OVERALL HEALTH (Check appropriate description)

excellent very good average fair poor

II. SPECIAL MEDICAL CONDITIONS OR PHYSICAL DISABILITIES

Describe any special medical conditions that you have that may interfere with your full and safe participation in any activity of the Coureurs de Bois Club Ottawa Inc. or which may jeopardize or bring risk to the safety or health of other participants in such activities. Include, where appropriate, any prescribed drugs used for treatment and any allergies.

________________________________________________________

________________________________________________________

________________________________________________________

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Signed: _________________________________________________

Witness: * ______________________________________________

Dated at ________________ this _________ day of _______, 200__

* Signature of parent or guardian required if under 18 years of age.

PART C - ADDRESS INFORMATION

Name: ________________________

Address: ________________________

City: _______________ Prov. _________________

Postal Code: __________________

e-mail: ______________________________________________
(for addition to our email list, please ensure this is easily readable!)

Home phone: ________________________ Work phone: ________________________

FAX: ________________________

Single or family memberships are $15.00 total, a signed form is required for each participant. Please return completed Membership & Waiver Form with membership fees ($15.00) to: Coureurs de Bois - Membership Jim Forbes 89 Ashgrove Cres. Ottawa On, K2G-0T2