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Project Jewel: Health Disclosure Form

INFORMATION ABOUT THIS FORM

CONSENT: The federal legislation protecting your privacy requires the IRC to obtain your consent to collect, use and disclose your personal information for identified purposes. By signing this form, you are giving your consent.

PURPOSE OF COLLECTING YOUR INFORMATION: Participants in Project Jewel may engage in strenuous outdoor activity, which some participants may find physically, emotionally and spiritually demanding. The personal and health information disclosed by the participant will only be used to help the Program facilitators prepare for and deliver the program as safely and effectively as possible.

DISCLOSURE OF YOUR INFORMATION: The information may be disclosed to program facilitators and staff of the Inuvialuit Corporate Group on a strictly as required for the operation of Project Jewel.

ASSUMPTION OF RISK: By collecting this information, IRC does not assume any risk on behalf of the participant. Please refer to the Participation Agreement for more information

Personal Information
Health Information
PARTICIPATION, ASSUMPTION OF RISK, RELEASE OF LIABILITY AND INDEMNITY AGREEMENT

Please read the following agreement carefully, since you will be waiving certain legal rights.

To: Inuvialuit Regional Corporation (IRC) and its directors, officers, employees, agents, guides, volunteers, independent contractors, representatives, successors and assigns.

have applied to participate in the IRC On-the-Land Program, Project Jewel (“Program”). I understand that this Agreement includes all activities, events or services provided, organized, conducted or authorized by IRC in relation to the Workshop.

ASSUMPTION OF RISK: I am aware that my participation in the Program is voluntary and may involve risks, dangers and hazards associated with a multi-day excursion on the land. I freely accept and fully assume all such risks, dangers and hazards, including the failure on the part of the IRC to safeguard or protect me therefrom, and the possibility of personal injury, death, property damage and loss.

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY: I agree TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the IRC, TO HOLD HARMLESS AND INDEMNIFY the IRC from any liability and to RELEASE the IRC from any and all liability for any loss, damage, expense, injury including death that I may suffer, or that my next of kin may suffer, resulting from my participation in any part of the due to any cause whatsoever in relation to the Program.

NO TRAVEL OR HEALTH INSURANCE PROVIDED: I understand that the IRC has not purchased any health, travel or other insurance on my behalf.

ZERO TOLERANCE: I understand that the Program is a Zero Tolerance program and if I bring or use alcohol or drugs (other than cigarettes or medication prescribed to me by a medical doctor) I will be immediately removed from the program.

RESPECT: I will demonstrate respect to facilitators, participants, the environment, cabins and all activities forming part of the Program. I will follow the direction of the facilitators and understand that if a facilitator perceives a risk to any program participant or other facilitator, he or she is authorized to remove me from the program. I will not use any machinery located at either cabin without permission and supervision of the owner.

RETURN TO TOWN: I understand that during the program we will not be traveling to town except in the event of emergency or to replenish necessary supplies.