Participants Name (required)
Participants Address (required)
Date of birth: dd/mm/yyyy (required)
Email contact (required)
Phone (required)
Emergency Contact: Name
Emergency Contact No (required)
Previous Experience
Medical Questionnaire and Consent (required) Do you suffer from any medical condition illness injury or disability that may interfere with or be aggravated by the proposed activity? YesNo If yes please provide details Is the above mentioned condition likely to require any special attention, treatment or medication during the activity? (required) YesNo If yes please provide details Have you ever had a serious allergic reaction to an insect, animal or plant? (required) YesNo If yes please provide details (including reaction & treatment): Can you swim 25 metres? YesNo
Indemnity Agreement & Waiver of Liability Teaching, Training & Assessment Events : Participants Name:(required) Age if under 18: 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 Date: dd/mm/yyyy
Payment: (to be made prior to commencement)
Direct Deposit. (Please use “Surname FW” as the reference.) Canoe Tasmania Inc. MyState Financial BSB: 807009 Acc No: 12245398
COURSE COST: $265
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
