This form is required of everyone attending Covenant camping trips, is for your own protection and is vital to your health and safety.
Please print it off and give the completed form to Jean. Just right click on the images below and follow the directions for your printer (the pages are separate images instead of docs to make them phone friendly * If you are doing this on your phone you may have to download before you can print. If you don’t have a printer, please let Council know so we can print one for you.
We need it printed so that all the information is in one place and easily accessible. Look at it this way – if emergency assistance is required we want to be able to tell the responders all the important things about your health. We also want to be able to call someone to tell them what is going on. Jean holds these in confidence. No one sees the forms, not even Jean, unless there is an emergency.
In the section where your medications are required, PLEASE put down everything, including over the counter (like Tylenol, decongestants, eye drops, etc.), vitamins, herbal supplements, and things you might only take once in awhile, like a rescue inhaler, migraine medication, anxiety meds, etc. If you are on a blood thinner please be very specific about the name of the medication and the dose you are on so an “antidote” can be administered by medical personnel, if needed.
NCCR Camping Trip Waiver
*Privacy Notice: All information is held in strict confidence and will not be used or disseminated for any purpose other than medical emergency*
Name:___________________________________________Address: _________________________________________ Phone: _________________________
Name(s) of all minors of which you are the legal guardian who will be in attendance and for which this waiver also covers:
________________________________ ___________________________________ ________________________________ ___________________________________
Do you have any lifethreatening allergies or conditions? YES ____ NO ___
If yes, please explain: ______________________________________________ ______________________________________________________________________________________________
Please list ALL medications you are currently taking: _____________________________________________________________________________________________________________________________________________
If you need more room please continue on the back of this sheet.
By signing this waiver I agree that:
● Precautions are taken for safety and health, but in the event of accident or sickness, NCCR, its members, and its volunteers are hereby released from any liability. There are certain risks and inherent dangers involved in camping and I take full responsibility for choosing to proceed and attend the NCCR camping trip with full knowledge and understanding of said risks and dangers including but not limited to: Injury or death due to trips, falls, exhaustion, dehydration, burns, wild animal interactions, weather, or unforeseen accidents. A number of tools will be present including but not limited to: axes, saws, shovels, tent spikes, guylines, campfires, cooking stoves and lighters. I am aware they will be present and it is solely my own responsibility to use said tools safely and to avoid injuring myself with them.
● I have notified the NCCR Council of any life threatening allergies and/or conditions which they need to be aware of, as well as any special precautions that are needed to attend to my personal safety.
● I authorize the members of NCCR to administer first aid to me and/or call emergency services for me in the event that I am unable to give my consent at the time care is needed and will not hold NCCR or it’s members liable for any damages, costs or injuries suffered from attempts to aid me.
Name of Emergency Contact: _______________________ Phone:_______________________
Address:_________________________________________
Relationship:______________________________________
By signing this waiver I acknowledge that I have read, understand and agree to abide by the contents of both this waiver and the NCCR Code of Conduct available here: https://covenantoftheriver.org/conduct/
Signature: _____________________________ Date:_____________
*Privacy Notice: All information is held in strict confidence and will not be used or disseminated for any purpose other than medical emergency*