Original document in French - English translated via DeepL.com RISK ACKNOWLEDGEMENT AND ACCEPTANCE FORM MUST BE COMPLETED BEFORE THE START OF THE LESSON Course / Clinic booked ? Name Surname E-mail Cell Name to contact in case of emergency Emergency phone number Name of parent if minor Parent's first name if minor Who referred you to bikeskills? 1) HEALTH CONDITION Age Gender MaleFemaleNon binary Do you have any symptoms associated with Covid-19? YesNo Have you traveled in the last 14 days? NoYes Have you been in contact with someone who has symptoms of Covid-19? NoYes Are you pregnant? Ne s'applique pasNoYes Are you taking any medications? YesNo If you are taking any medications, which ones? Do you have any physical, emotional, or behavioral health issues that would directly or indirectly limit you from participating in the activity you will be participating in? Examples: Breathing problems, heart problems, diabetes, vision problems, deafness, vertigo, fear of heights/dogs, limitation of your movement, previous injuries? Do you have any allergies? Do you have any concerns about mountain biking? If you answered yes to any of the items in Section 1, YOU MUST MEET WITH THE COACH AND REPORT THIS TO HIM. By submitting this information to bikeskills, I accept the additional risk that my health may deteriorate Please choose: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 2) RISKS INHERENT TO THE ACTIVITY I acknowledge that I have been informed of the risks inherent to the activities that are part of the pmbiaquebec.ca program. The risks of the "Mountain Bike Technical Course" activity in which I will participate are, in particular, but not limited to - Injuries due to falls on the bike - Injuries due to contact with an object (bike, tree, branch, rock) - Injuries due to intense physical effort - Injuries due to changing weather conditions (hypothermia, heat stroke) - Injuries resulting from accidental or unintentional contact between individuals - Food allergy (if applicable) Please choose : —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 3) CONFIRMATION OF INFORMATION AND ACCEPTANCE OF RISKS I certify that the information on this form is accurate to the best of my knowledge. I certify that I have not deliberately omitted any information about my health status, whether relevant or not. I am aware that the information contained in this form is confidential and is intended to better plan and supervise the safety of the activities in which I will participate and that it will allow bikeskills to draw up a profile of its clientele. I am aware that the activities offered by bikeskills take place in semi-natural or natural environments that may be rugged and, consequently, are further away from medical services. This could result in long delays in the event of an emergency requiring evacuation, and consequently, a possible aggravation of my condition or injury. Having been made aware of these risks and having had the opportunity to discuss them with a person in charge of the activity, I acknowledge that I have been informed of the risks inherent to the activities and that I am able to undertake the activity in full knowledge of the facts and accepting the risks that this activity may entail. I also agree to play an active role in managing these risks by adopting a preventive attitude towards myself and others around me. The coach reserves the right to exclude any person he/she deems to be a risk to him/her or the rest of the group. I understand that I may leave this activity for any reason. Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 4) DRUGS AND ALCOHOL I agree that I will not use, possess or be under the influence of any drug, illegal substance or medication (prescription or not) that is not mentioned in section #1 of this form. I also confirm that I am not under the influence of alcohol or recreational drugs and that I will remain so for the duration of the activity. I am aware that any breach of these rules on my part may result in my expulsion without notice and without the possibility of a refund. Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 5) DISCHARGE OF MATERIAL RESPONSIBILITY I, the undersigned, hereby waive all claims, as well as all lawsuits for damages to my property and equipment. (normal wear and tear, loss, breakage, theft, vandalism.) Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 6) AUTHORIZATION TO INTERVENE IN CASE OF EMERGENCY I, the undersigned, authorize the responsible bikeskills coach to render all necessary first aid. I also authorize the responsible bikeskills coach to make the decision in the event of an accident to transport me (by ambulance, helicopter, coast guard or otherwise) to a hospital or community health facility, all at my own expense if necessary. Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 7) COVID-19 and Lyme disease I understand the risks associated with Covid-19 coronavirus and Lyme disease, and I waive any and all claims and damages resulting from inadvertent transmission. Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) 8) Acceptance of risk and release to the practice site or municipality hosting Bikeskills I waive all claims for damages against the partners of bikeskills hosting the coaching activities. Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised) I have read, understand and agree to the terms and conditions set forth in this risk acceptance form and agree to abide by them. I also attest to the truthfulness of the information provided to bikeskills. In witness whereof, I am providing my consent as of today's date by selecting the "I agree" box. Choisir: —Please choose an option—I ACCEPT / (this acts as a signature)I do not accept (your participation will be compromised)
