Thank you for your interest in youth programming at Yukonstruct! We're excited to see you next week. Please fill out the following form in advance of the workshop.

PARTICIPANT INFORMATION

Parent/Guardian Name (the person who purchased the ticket):

Parent/Guardian Email:

Participant Name:

School:

Grade:

CONTACT INFORMATION

Street Name/Number:

City:

Territory:

Postal Code:

Phone:

EMERGENCY CONTACT INFORMATION

Emergency Contact Name:

Emergency contact daytime phone:

Emergency contact evening phone:

MEDICAL INFORMATION

Does the participant have any existing medical conditions which would affect your ability to participate: YesNo

If yes, explain:

Does the participant have any allergies? YesNo

If yes, please list any allergies:

SPECIAL NEEDS

Does the participant have any special needs (physical, language, etc) that will require support? YesNo

If yes, please describe the needs and support required:

LIABILITY RELEASE

ASSUMPTION OF RISK: I hereby acknowledge that there are inherent risks, dangers and hazards when participating in activities held at or sponsored by Yukonstruct Society, including the use of various tools associated with design, experimentation, fabrication, construction and other related activities. I understand that participation in such activities and the use of such equipment may result in injury, illness, death or damage to personal property. These risks and dangers may be caused by other participants, or by accidents, acts of nature or other causes. Risks and dangers may arise from foreseeable or unforeseeable causes and may include, but are not limited to: electrocution, burns, impalement, injury from slips or falls, etc.

RELEASE OF LIABILITY: I hereby release Yukonstruct Society and its members, officers, agents, and board members from any action whatsoever arising out of any damage, loss or injury to the named participant or their property while upon the premises, or while using any equipment of the organization or others, or while participating in any of the activities contemplated by this agreement; whether such loss, damage, or injury results from the negligence of the corporation, its members, agents, or from some other cause.

COVENANT NOT TO SUE: I hereby agree never to institute any suit or action at law otherwise against Yukonstruct Society, its members, officers, agents or board members; nor to initiate or in any way assist the prosecution of any claim for damages or course of action which myself, my heirs, my executors or my administrators hereafter may have by reason of injury to the named participant or to their my property arising from the activities contemplated by this agreement.

THIRD PARTY INDEMNIFICATION: I hereby agree to indemnify, save and hold harmless Yukonstruct Society, its members, officers, board members, or agents from any and all losses, claims, actions, or proceedings of every kind and character which may be presented or initiated by any other persons or organizations and which arise directly or indirectly from the named participant’s actions while engaged in the activities contemplated by this agreement.

MEDICAL RELEASE: I do voluntarily authorize Yukonstruct Society, their representatives, facilitators, instructors, volunteers, and employees to obtain routine or emergency diagnostic procedures and/or routine emergency medical treatment for the named participant as deemed necessary in medical judgment. I agree to indemnify and hold harmless Yukonstruct Society, their representatives, facilitators, instructors, volunteers, and employees for any and all claims, demands, actions, rights of actions, and/or judgment by or on behalf of the named participant arising from or on account of said procedures and/or treatment rendered in good faith and according to accepted medical standards.

PHOTO RELEASE: I agree that still photographs of the named participant taken during the program may be used and reproduced by Yukonstruct Society and their assigns and licensees from any liability in relation to using my image including claims for either invasion of privacy or libel.

I hereby acknowledge that I have carefully read all of the provisions above and fully understand the terms and conditions expressed there, and that I do freely choose acceptance of the provisions of the foregoing paragraphs relating to assumption of risk, release of liability, covenant not to sue, 3rd party indemnification, medical release, and photo release.

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Signature Certificate

Document name: Youth Programming Waiver

Unique Document ID: f99c2f1b7d0952dea9ceac275ccf6211ba14eb4c

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Timestamp	Audit
May 3, 2023 9:16 am MST	Youth Programming Waiver Uploaded by Rick Yorgason - info@yukonstruct.com IP 199.85.230.54
May 3, 2023 9:18 am MST	Rick Yorgason - rick@yukonstruct.com added by Rick Yorgason - info@yukonstruct.com as a CC'd Recipient Ip: 199.85.230.54

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