BIYC Student Info & Liability Waiver Form
From Biyc
Please print, fill out and return to BICR office BEFORE JUNE 30. Download pdf form here: Image:Liability waiver form.pdf
Note: Your child is not eligible to participate until the form is received.
Name of Student :________________________________________________________
Course:_____________________
Date of birth:_________ Age:______ Male/ Female
Contact Info
Mother: Home_______________ work_________________ Cell_________________ Email_________________
Father: Home_______________ work_________________ Cell_________________ Email_________________
Emergency Contact Name:_________________ Home_______________ work_________________ Cell_________________
Doctor __________________________ Office phone_____________________
BC Medical Card Number____________________________________________
Does the student suffer from any life threatening conditions (such as diabetes, epilepsy, anaphylactic shock)? Y__ N__ If yes, please describe:
Does the student suffer from any other health risks? Y__N__ If yes, please describe.
Does the student have any special needs or require special attention? Y__N__ If yes, please describe.
WAIVER AND RELEASE All participants in this Program do so at their own risk and by completing this entry form the parents and guardians specifically agree to indemnify and hold harmless the Bowen Island Yacht Club, its organizers and its agents, officials, servants, sponsors, and representatives from and against all claims, actions, costs, expenses and demands in respect to death, injury, loss or damage to any person or property, arising out of or in connection with participation in this Program, notwithstanding that the same may have been contributed to or caused or occasioned by the negligence of the same bodies, or any of them, or their agents, officials, servants or representatives. I grant Bowen Island Yacht Club permission to photograph my child and use the photo and/or other digital reproduction of him/her for publication purposes, whether electronic, print, digital or electronic publishing via the Internet, without payment or any other compensation. I represent to the Bowen Island Yacht Club that my child is a willing participant to this Program.
Agree__ Do not agree__ (Note: if blank or if you do not agree, your child will not be eligible to participate)
_________________________________________________________ Signature of Parent or Guardian
_________________________________________________________ Printed Name of Parent or Guardian
_________________________________________________________ Date
