Participant Name
*
First Name
Last Name
Email
*
Phone
(###)
###
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1. Please rate your swimming ability and experience by ticking the appropriate box:
*
The below self assessment will be used in conjunction with our own instructors / organisers onsite assessment of the participant to make an informed evaluation on the participants ability to safely partake in Watersport activities to match their skill level and ability in the activity and conditions. If the participant feels anxious or uncomfortable with any activity at any stage they must communicate this to the instructors / organisers.
2. Please rate your surfing ability and experience by ticking the appropriate box:
*
Identity.
I allow photographic and or visual images taken by organisers of myself participating in the Tour/Trip may be used for general promotion and marketing purposes by the organisers. Note: your answer does not impact in your ability to participate in activities in anyway.
Physical Fitness.
I must not participate in the Tour/Trip if I have any injury, disability, medical or health condition that may increase the risk of me becoming injured unless I have told organisers about it and they have authorised me to participate at my ongoing risk. I declare that I am medically and physically fit and able to participate in the Tour/Trip and I will immediately notify organisers of any change to my fitness and ability to participate. I understand and accept that organisers will continue to rely on this declaration as evidence of my fitness and ability to participate.
Please list any medical conditions which may prevent / impede you from being able to fully participant in activities that organisers should be aware of:
Allergies
Please list any known food or other allergies that organisers should be aware of:
Note: Participants health information is private and confidential and will not be shared with any parties that are not relevant to the safety of the participants.
Emergency Contact Person no. 1
*
First Name
Last Name
Phone
(###)
###
####
Emergency Contact Person no. 2
First Name
Last Name
Phone
(###)
###
####
In consideration of organisers accepting my application to participate in the Tour/Trip, I acknowledge, understand and agree that: Compliance. I will at all times comply with the instructions and safety procedures of the organisers. Emergency treatment. If unable to contact participants emergency contacts listed on this document, I allow organisers to arrange medical or hospital treatment (including ambulance transportation) for the participant in the event of an emergency and I authorise such actions being taken by the organisers and agree to meet all costs associated with such action. Risk. While every effort is made by organisers to negate risks, I understand that partaking in surfing and other activities (both land and water based) there are inherent risks of injury and harm. I understand the nature and requirements of the Tour/Trip and acknowledge that serious accidents can happen which may result in me being seriously injured or death. I have voluntarily read and understood this warning and accept and assume the inherent risks in participating on the trip and the activities. Release & Indemnity. My participation in the Tour/Trip is entirely at my own risk and I agree to: (a) release and forever discharge the organiser from all liability and *claims that I may have or may have had but for this release arising from or in connection with my participation in the Tour/Trip; (b) indemnify and hold harmless the organiser to the extent permitted by law in respect of any *Claim by any person including but not only another participant in the Tour/Trip arising as a result of or in connection with my participation in the Tour/Trip. *“Claims” means and includes any action, suit, proceeding, claim, demand, damage, penalty, cost or expense however arising (including negligence, trespass to the person or for breach of implied terms in the sale of services under section 74 of the Trade Practices Act (1974) Cth and equivalent provisions contained in State sale of goods or fair trading legislation). Privacy. I understand that the information provided by me in is form is necessary for the operation of the Tour/Trip. I acknowledge and agree that the information will only be used for the objects of Tour/Trip and to provide me with information pertaining to the Tour/Trip and operator activities. I understand that I will be able to access my information through KISS upon request. If the information is not provided I might not be permitted to participate in the Tour/Trip. I have read, understood, acknowledge and agree to the above declaration including the warning, release and indemnity. “Organisers” for the purposes of this declaration means King Island Surf Safaris PTY LTD (KISS) and includes, where the context so permits, their respective directors, guides, coaches, staff, contractors, partners and servants. “I/You/Your/Me/student/customer” for the purposes of this declaration means the participant wishing to partake in the tour/trip/activities.
*
Where the applicant is under 18 years of age this form must be signed by the applicant’s parent or legal guardian.
First Name
Last Name
Date
MM
DD
YYYY
