NOTE: Haliburton Forest & Wildlife Reserve Ltd. does not accept paper waivers, please submit electronically.

Health Record:

Date:

Child's Name:

Health Card Number:

Date of Birth:

Age:

Gender

Allergies/Dietary Restrictions (i.e. insect stings, drugs, foods, etc.):

Do you require an Epi pen for allergic reactions?

Immunization Record of Tetanus Vaccination (are you up to date and if possible provide dates):

List medication to be taken while on trip with doses and times:

Do you suffer from any physical or health disability that would affect your ability to participate in any of the activities outlined in the schedule? If so please describe:

Recent injuries, illnesses, operations:

Parent Contact Name:

Parent Phone Number:

Family Physician Name:

Family Physician Phone Number:

Emergency Contact (other than parent above):

Emergency Contact Phone Number:

_____________________________________________________

Forest Use Guidelines

All visitors to Haliburton Forest are advised of the fact that Haliburton Forest in general is a wilderness area. It is therefore expected that all visitors are familiar with basic concepts and dangers inherent to the use of the outdoors and are prepared accordingly.

The following are a number of conditions and safety rules that must be met by user groups:
1. Damages to property and equipment, above normal wear will be the responsibility of the individual or group. Repair and or replacement costs will be the responsibility of the individual or group.
2. No part of standing trees shall be cut or mutilated.
3. Do not trespass on the property surrounding trailers, campsites or hunt camps.
4. No firearms are permitted without written consent.
5. Garbage is to be removed off the property at the time of departure and or deposited int he appropriate disposal units at the Base Camp.
In particular but not withstanding further additional dangers:
1. Haliburton Forest advises visitors not to feed wildlife.
2. Haliburton Forest strongly advises visitors not to use water from lakes or streams for human consumption without treatment by boiling or chemical means.
3. Haliburton Forest must be informed immediately of any incident involving personal injury and or property damage that has occurred while using Haliburton Forest property.
4. Haliburton Forest cannot and does not pretend to list or eliminate all the hazards associated with use of the property, visitors are advised to use caution at all times.

Consent:

Having filled out the medical information, read and understood the conditions outlined above, I consent for my child to participate in the activities at Haliburton Forest and Wild Life Reserve Ltd.

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Consent Signature of Parent/Guardian:

Waiver of Liability:

I understand and agree to release Haliburton Forest and Life Reserve Ltd., its directors, officers, employees and agents, from all liability and to assume the risk of any injury, including death, contracting of an infectious disease and any loss or damage that may be incurred while visitng or using the site, facilities and equipment at Haliburton Forest, however caused, and whether caused by negligence while participating in activities at Haliburton Forest.

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Liability Signature of Parent/Guardian:

Photo Release:

From time to time our staff take pictures an/or video. These pictures/video may or may not include your child. These pictures may be used for promotional purposes in print, digital or other media. Haliburton Forest is only responsible for official uses of pictures/videos. Any personal uses by participants and other visitors to Haliburton Forest outside of promotional uses outlined above are not monitored by or the responsibility of Haliburton Forest.

I hereby consent or do not consent on behalf of my child being photographed and/or filmed and for those images to be used as outlined above by Haliburton Forest and Wild Life Reserve Ltd.

Photo Release Consent

CONSENT

DO NOT CONSENT

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Photo Release Signature of Parent/Guardian:

Electronic Signature Consent

By checking here, you acknowledge you have read and understand the above terms, and 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.

NOTE: Haliburton Forest & Wildlife Reserve Ltd. does not accept paper waivers, please submit electronically.

Youth Health Record, Consent, Waiver of Liability, Photo Release & Forest Use Guidelines