Wilderness Participant Forms

Form 1 of 2: Liability Waiver Wilderness Courses

RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT

All participants attending a FACT Plus Inc. (FACTPlus.ca) Wilderness Course must complete this Liability Release Form before they can participate.

Please note that this is a "generic" waiver that encompasses ALL activities done in a variety of FACT Plus Inc. courses. Some courses may not encounter or participate in many of the activities listed in this waiver of liability.

Please complete each section below.

PLEASE READ CAREFULLY.

* THIS RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY AGREEMENT IS INTENDED TO ENABLE PARTICIPANTS TO BETTER UNDERSTAND AND ACCEPT THE VARIOUS RISKS INVOLVED WITH PARTICIPATING IN THE AFOREMENTIONED COURSE/EXPEDITION.

** ALL PARTICIPANTS WILL BE REQUIRED TO SIGN THIS AGREEMENT AS A CONDITION OF THEIR PARTICIPATION AND THEREBY RELEASING FACT Plus Inc. (FACTPlus.ca) AND ALL OTHER RELEASED PARTIES FROM ANY FUTURE CLAIMS WHICH MIGHT ARISE AS A RESULT OF PARTICIPATING IN THE AFOREMENTIONED COURSE/EXPEDITION.

In this Agreement,

“RELEASED PARTIES” means FACT Plus Inc. (FACTPlus.ca) and its members including but not limited its officers, Owners, employees, assigns, volunteers, agents, representatives, contractors, instructors and participants including other students/participants.

“FACT” refers to the FACT Plus Inc.

BY ENTERING INTO THIS AGREEMENT, I AM NOT RELYING UPON ANY ORAL OR WRITTEN REPRESENTATIONS OR STATEMENTS MADE BY THE RELEASED PARTIES OTHER THAN WHAT IS STIPULATED IN THIS AGREEMENT.

* Participants First Name

* Participants Last Name

Participants email * unless the participant is a minor child, the Email address should be the parent/guardian.

Who is completing this form

I am an Adult, this waiver is for Me, I am taking the course.

I am an Adult, this waiver is for my minor child who is taking the course

The participant is registered for the following course:

Wilderness & Remote First Aid Course

Advanced Wilderness & Remote First Aid Course

Bridge to upgrade to the Advanced Wilderness & Remote First Aid Course

Please idendtify your course "Start Date":

In consideration of the educational services and programs offered by FACT Plus Inc. (herein after referred to as “FACT”), I (joined by my parents or legal guardian if I am a minor attending any courses other than the Wilderness & Remote F), herein after referred to as the “participant” or “student”, agree to the following terms and conditions and acknowledge the following:

This document is to be completed as my acknowledgement that I understand that ACTIVITIES AND RISKS associated with my participation in the above course, and that I understand that FACT Plus Inc. considers it important for me to know in advance what to expect and to be informed of the activities’ inherent risks.

The following describes some, but not all, of those risks associated with my electing to participate in this course.

Activities & Risks May Include:

FACT Plus Inc. activities may include strenuous activities both, physically and emotionally. Physical activities may include running, hiking, repetitive lifting and carrying. Certain activities will require travel by foot and other means, over unimproved roads, hiking trails and rugged off-trail terrain including downed timber, river crossings, snow, ice, steep slopes, slippery rocks and other features, Students/Clients may (in rare cases) be moved via Snowmobile, ATV, Boat, Car or Other Motorized Vehicles. These travel risks include falling, Collisions, Injuries, drowning, becoming lost and others usually associated with such travel, including environmental risks. Environmental risks and hazards include flowing, deep and cold water; Falling Through Ice, insects, snakes, animals; falling and rolling rock; lightning, falling timber, and unpredictable forces of nature, including weather which may change to extreme conditions without notice.

Possible injuries and illnesses include hypothermia, frostbite, sunburn, heatstroke, dehydration, Heart Arrhythmia, Sudden cardiac Arrest, and other mild or serious conditions. Students/Clients will participate in realistic simulated injury and illness scenarios and will at times act the role of patient, being handled, carried and otherwise treated as patients of a medical emergency in simulated situations.

Students/Clients will also use and practice with various medical equipment. Training, under close staff supervision, may include the option of injecting, and being injected, by fellow Students/Clients. Risks associated with this training include being inadvertently stuck by a needle, being dropped or otherwise mishandled while being carried; unwelcome touching while acting the role of patient in a scenario; and emotional distress in response to training scenarios.

Decisions made by the instructors, other staff (including volunteers), contractors and Students/Clients will be based on a variety of perceptions and evaluations which by their nature are imprecise and subject to errors in judgment. Misjudgments may pertain to, among other things, a student’s capabilities, environment, terrain, water and weather conditions, natural hazards, routes and medical conditions.

FACT Plus Inc. Students/Clients, including minors, may have “free” time before, during and after their FACT Plus Inc./FACT Wilderness & Remote First Aid courses, or other courses in which they have chosen to participate in. FACT has no responsibility for Students/Clients during this free time. FACT staff may from time to time provide assistance or even accompany Students/Clients in these free time activities, but in doing so, they are acting as private individuals, and FACT is not responsible for their conduct. Even during the wilderness medicine course, FACT cannot continually monitor the behavior and activities of Students/Clients and Students/Clients must accept responsibility for themselves and others whether or not under the direct supervision of FACT staff.

Acknowledgement:

Yes, I acknowledge and I understand the potential "Activities Risk"

Yes, I acknowledge and understand and acknowledge that the description above (“Activities and Risks”) of the inherent risks of FACT’s activities is not complete and that other, including unknown or unanticipated, risks, inherent or otherwise, may result in property loss, injury, illness or death.

Yes, I acknowledge that my participation in this FACT course is purely voluntary, and I wish to participate in spite of and with knowledge of the inherent and other risks involved. I acknowledge and assume the inherent risks described above and all other inherent risks of my FACT course.

In addition, except with respect to an injury or other loss which occurs on lands whose rules or regulations prohibit my doing so as a matter of law, I expressly assume ALL risks of enrolling and participating in a FACT course, inherent or otherwise, and whether or not described above.

AGREEMENTS OF RELEASE AND INDEMNITY

AGREEMENTS of RELEASE & IDEMNITY: I hereby agree to release and hold harmless FACT, the sponsor of the training course, it’s officers, trustees, agents, and staff including employees, volunteers and affiliates. (“Released Parties”), with respect to any and all claims of loss or damage to person or property by reason of injury, disability, death, or otherwise, suffered by me "or" by a minor student for whom I sign, arising in whole or part from my, or the minor student’s, enrollment or participation in an activity of FACT or transportation to and from such activities.

I agree

I agree further to indemnify (“indemnify” meaning to defend, and to pay or reimburse including costs and attorney’s fees) Released Parties against any claim by a member of my, or the student’s, family, a rescuer, another student, or any other person, arising in whole or part from an injury or other loss suffered by me or caused by me, or by the minor student, in connection with my, or the minor student’s, enrollment or participation in an activity of FACT.

I agree

I agree to be responsible for any damage I, or the minor student, may cause to the property of FACT or others. FACT is not responsible for loss, theft or damage to a student’s personal belongings at any time during the course, including storage by FACT or others.

I agree

FACT and persons designated by it may use my or the minor student’s photograph for sale or reproduction in any manner FACT chooses, including for advertising display, audiovisual presentations or otherwise.

I agree

Any dispute between me, or the minor student and FACT will be governed by the substantive laws (not including the laws which might apply the laws of another jurisdiction) of the province of Ontario or the province in which the course is being taught. If any part of this agreement is found by a court or other appropriate authority to be invalid, the remainder of the agreement nevertheless will be in full force and effect.

I agree

Please Read & Sign Below

I, the above named participant (or parent/guardian of the participant) hereby affirm that I understand that my participation on expeditions and training courses with FACT involves exposure to certain RISKS, DANGERS AND HAZARDS which could result in consequences including PROPERTY DAMAGE OR LOSS, PERSONAL INJURY, AND DEATH.

I also UNDERSTAND AND AGREE that such RISKS, DANGERS and HAZARDS include but are not limited to:

1. Travel and survival in the wilderness;

2. exposure to elements such as changing weather conditions which may result in hypothermia, frostbite, hypothermia, sunburn, insect bite, etc.;

3. varying environmental conditions and varying wilderness conditions which may result insect bites, etc.;

4. exposure to wildlife; and

5. risks associated with the use of motor vehicles used for transportation to and from courses and or, specialized equipment and the operation of machinery such as ATVʼs, snowmobiles, boats, etc.

I AFFIRM THAT the level of physical fitness and endurance of the participant IS ADEQUATE for participating on the training course;

I FURTHER STATE THAT I HAVE OR WILL HAVE COMPLETED; TO THE BEST OF MY KNOWLEDGE, the FACT Confidential Medical History Form and that FACT will rely upon the medical information disclosed therein.

I will VERIFY WITH MY PHYSICIAN, if I deem necessary, to ensure that I do not have any physical or psychological problems which could create undue risk to myself or fellow participants on the expedition or training course;

I UNDERSTAND THAT I AM RESPONSIBLE for educating myself in all applicable risks, to weigh those risks against the advantages, and to decide whether or not to participate in the aforementioned course/expedition.

I FURTHER UNDERSTAND AND AGREE that the only way I can completely eliminate all risks related to participating in sanctioned activities is to choose not to participate in them, which I UNDERSTAND I am free to do at any time and for any or no reason.

I UNDERSTAND THAT I HAVE THE OBLIGATION TO COMPLY WITH ALL DIRECTIONS and INSTRUCTIONS set forth by FACT before and throughout the course/expedition.

I UNDERSTAND AND AGREE that the non completion of the course/expedition due to voluntary/compulsory withdrawal, lack of participation or caused by my physical or mental inability to meet the aforementioned course/expedition requirements will result in a failure to meet the required criteria for certification.

I UNDERSTAND AND AGREE that following a failure to achieve certification requirements for the aforementioned course/expedition any deposit, travel and or tuition costs are non-refundable. FACT will reserve the right to grant me a second opportunity in a future course/expedition should an opening be available; however, this is not an obligation on the part of FACT and each situation will be reviewed on a case by case basis.

I UNDERSTAND AND AGREE TO WAIVE ANY AND ALL CLAIMS, ACTIONS, COSTS, EXPENSES AND DEMANDS that I may have against ALL RELEASED PARTIES.

TO RELEASE ALL RELEASED PARTIES from any and all liability for any LOSS, DAMAGE, INJURY, or EXPENSE that I, or my next of kin, may suffer or incur as a result of my participation on this course/expedition.

I FURTHER RELEASE, EXEMPT AND HOLD HARMLESS FACT AND ALL OTHER RELEASED PARTIES from any and all liability for property damage, personal injury or death suffered by myself or by a third party as a result of my participation on the expedition or training course.

I UNDERSTAND THAT THIS RELEASE AND INDEMNITY AGREEMENT SHALL BE EFFECTIVE AND BINDING upon

my heirs, next of kin, executors, administrators, and assigns, in the event of my death.

I FURTHER STATE that I am of lawful age and legally competent to sign this liability release and if I am not that I have acquired the written consent of my parent or guardian who is of lawful age and legally competent to sign this liability release.

I UNDERSTAND the terms herein are contractually binding and not a mere recital and that I have signed this Agreement of my own free will and with the knowledge that I hereby agree to waive my legal rights.

I FURTHER AGREE that if any provision of this Agreement is found to be unenforceable or invalid that that provision shall be severed from this Agreement and that the remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein.

I UNDERSTAND AND AGREE that I may be photographed and or filmed during the aforementioned course/expedition and that media may be used by FACT for promotional and marketing purposes via print or electronic means.

I AGREE THAT THE LAWS OF THE PROVINCE OF ONTARIO govern this contract.

I State that I have declared & made the course Instructor & FACT Plus Inc. aware of any pre-existing or pertinent Past Medical History which could affect my willing being or safety during my participation in the course or activity I have chosen to participate in.

I accept terms & conditions

Electronic Consent

By signing below, the student (and parent or legal guardian of a minor student) has read this agreement and understands and agrees to its terms, including the acknowledgements and assumptions of risk, agreements of release and indemnity and the additional provisions, stated above.

I am also acknowledging that I have and the information listed on the www.FACTplus.ca/faq

website under Frequently Asked Questions (FAQ) menu pertaining to:

How to dress for the course
What to bring with you
Medical Conditions
Meals
Accommodations
Alcohol, recreational Drugs policy
Weather Conditions
Tobacco
Privacy Policy & Information Collection
Cancellation, Payment and Refund Policy

I am acknowledging that as the guardian of a minor child who is participating on this course, I have reviewed this document, and the FAQs listed on our website.

Signature

By signing below, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

TYPE YOUR NAME BELOW AS PROOF OF SIGNING. ** Parent/Guardian must submit on behalf of a minor child.*

The above document was read, acknowledged and signed on this date:

Select a Time

Signed in the city/town of

in the province of

Thanks for submitting form 1 or 2, liability Waiver Form. We sincerely appreciate your cooperation.

FORM 2 of 2:

Emergency Contact & Participant Medical History Form

The information provided on this form is being collected to assist in the event of an emergency situation.

It is recommended that your emergency contact(s) have knowledge of any medical condition(s) you may have.

The original of this form will be kept in a secure file in the FACT Plus Inc. main office and a copy will be kept in a sealed envelope with the Primary Person in Charge in the field to take to the hospital or provide to Medical first responders in the event of a medical emergency.

Again, the information provided will be printed and placed in a sealed field envelope will handed to the client upon completion of the course with FACT Plus Inc. The other copy will be kept secure lock and key cabinet for five years and then shredded.

All individuals participating in a field activity should be reasonably fit and have no medical conditions which could potentially be expected to result in a life-threatening situation.

If you have a serious medical condition or a condition that could be exacerbated during this time it is your responsibility to provide information on those conditions to assist with ensuring your health and well-being during the field activities (e.g. severe allergies, asthma, bleeding disorder, diabetes, epilepsy, heart condition, pregnancy).

If you are taking medication or require special medical/physical equipment, you should take an adequate supply for the length of the field activity. Any prescription medication that could affect your ability to perform the tasks required; or reduce your level of concentration or ability to respond should be disclosed.

If you/the participant is prone to needing me over the counter/herbal medications for typical ailments including but not limited to: such as, headaches, migraines, nausea, aches, pains, these must be disclosed, and should be brought with you. None will be provided.

Recreational medication should not be brought, or consumed during your course with FACT First Aid Certification Training as it may impair judgement, and could pose a potential safety/medical risk to the participant or others.

It is recommended that all individuals participating in a field activity should have a current tetanus booster.

Freedom of Information and Protection Act:

The personal information collected on this form is collected under the authority of the FOIPP Act to assist in the provision of care in emergency situations.

The information provided will be reviewed by FACT Plus Inc. Training/administration staff and the primary Instructor of your course. Personal information is protected under the FOIPP Act.

For further information, contact the Administrative Manager:

343-362-2631

info@FACTPlus.ca

Participant Contact Information

"Legal" First Name of Participant

"Legal" Last Name of participant

Date of Birth of participant

E-mail (if minor child parent/guardian):

Phone number or parent/guardian (if minor child) phone numbers:

Emergency Contact Information

Emergency Contact Name:

Emergency Contact Phone numbers:

Particpants relationship to the Emergency Contact. (***Note please be sure to inform your emergency contact that you have listed them, and provide them witht he course information and details.***)

Participants Medical Information

Current or previously diagnosed medical conditions: Please select any/and all:

Asthma (including in the past even if no recent incidents have occurred)

Bleeding disorders (such as but not limited to hemophilian, von willibrand's disease...)

Cardiac/Heart conditions/history or diagnosis related to cardiac/heart problems or chest pain

COPD- Chronic Obstructive Pulmonary Disease

Diabetes

Epilepsy or any conditions that have caused the particpant to have a seizure

High blood pressure

Low blood pressure

Stroke or TIA - Trans Ischemic Attacks

None of the above.

Asthma (current or previous diagnosis) check all that applies regarding the participant below

No Asthma

Asthma is sports induced

Asthma is environmental induced

Participant does carry an inhaler

Participant does NOT carry an inhaler

Last known asthma episode/attack was: (Type "NA" if this does not apply)

Allergies: please check all that apply

No known allergies

Foods (please provide details below)

Bugs (please provide details below)

Medications (plese provide details below)

Latex

participant carries an EPI-Pen

participant takes allergy medication

Allergy details: please detail what the participant is allergic to, and, what happens in the event of an exposure to the allergen. (Type "NA" if this does not apply)

Does the participant take medications incl. prescription, over the counter, herbal and or recreational?

List Medications incl. prescription, over the counter, herbal and or recreational taken by the participant. Type "no medications are taken" if this does not apply.

Surgery history: please list any surgeries the participant has had. (Type "none" in the event of no surgeries).

Injuries (current or pre-existing): please identify any/all previous injuries of the following areas:

Back

Neck

knees

hips

wrists

hands (including fingers)

ankles

feet (including toes)

Concussions or head injuries

Arms (including shoulders)

None of the above

Current or pre-existing injury details: f you checked yes to a previous injury, or there is an injury which is not listed, please provide us with some details about the injury. ( Type "none" if this does not apply)

Mental Health History: Due to the nature and intensity of the training we offer, we use realistic simulations and scenarios. This includes the use of make up to simulate both minor and severe injuries. By answering the questions below, it is important that FACT First Aid Certification Training provide a safe training ienvironment for you, and others. We would like to make our instructor aware of any of this history so that the instructor can adjust their lessons accordingly **Important: Answering in the affirmative in no way jeapordizes participation.*

PTSD - Post Traumatice Stress Disorder,

OSI - Operational Stress Injury

Anxiety, or panic attacks

other emotional factors we can assist in accomodating

None of the above

Other Medical information: Does the participant have any other medical conditions, limitations or history that could affect your safety, comfort or well-being of the participant, other course participants, course staff that the instructor should be aware of while you are training with us? (If no, please state "no")

Affidavit

I hereby state that I have included all information to the best of my knowledge and truthfully relating to my physical condition prior to conducting this course. I have made the course instructor aware of any medical conditions I may have.

I realize that admission of a medical history is not grounds for dismissal from the course however I assume all risk and release FACT Plus Inc. from any liability should my condition be adversely effected by the course content or its nature.

By selecting the "Yes I Sign below" option below & "Typing My Name" shall serves as an electronic signature and my agreement and acknowledgment of:

1. I acknowledge that I have informed my Emergency Contact(s) of this designation and all aspects of the field activity including the nature of any potential hazards.

2. I consent to the disclosure of the information in this document as necessary in the event of an emergency.

3. I acknowledge that it is my responsibility to disclose any medical, or other, condition that could endanger

my health and safety and that of my fellow participants.

4. I ACKNOWLEDGE THAT NO SPECIAL RELATIONSHIP IS CREATED BETWEEN FACT PLUS INC. AND MYSELF DUE TO ANY MEDICAL DISCLOSURE OR EMERGENCY CONTACT APPOINTMENT MADE HEREIN.

5. DISCLOSURE OF THE INFORMATION HEREIN SHALL NOT CREATE A DUTY OF CARE BETWEEN FACT PLUS INC. AND MYSELF, THE PARTICIPANT, AND PARENT/GUARDIAN OF THE PARTICIPANT.

ACKNOWLEDGEMENT: I hereby sign the document

Acknowledgement: typing your name below shall serve as an electronic signature on your behalf. (Parent/Guardian to place their name here if signing on behalf of a minor child.

I am the legal guardian/parent of the participant who is a minor child, under the age of 18 & I am legally signing on their behalf and have the authority to do so.

Signed on this date:

Signed at this time:

Signed in the city of:

in the Province of:

Thank you for your cooperation in submitting this form! Please look through our "FAQ Frequently Asked Questions" section for more information. Our admin team will send you an information package approximately one week prior to the start of your course, BUT, if you have any questions before then, please send us a message or give us a call!

Form 1 of 2: Liability Waiver Wilderness Courses

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AGREEMENTS OF RELEASE AND INDEMNITY

Participant Contact Information

Emergency Contact Information

Participants Medical Information