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140 College Drive Pottstown, PA 19464 484-945-0200 Managed by the Schuylkill River Greenway Association.

Schuylkill River Sojourn June 2 - 8, 2012

The Official Kayak of the Schuylkill River Sojourn 2012

SCHUYLKILL RIVER SOJOURN 2012


The Schuylkill River Sojourn is a 7-day, 112 mile guided canoe and kayak trip with a wealth of activities, learning opportunities and fun on the Schuylkill River and in riverside communities. Your registration includes a t-shirt, meals, a vehicle to transport your gear (please limit gear to 2 medium or large duffels per person-waterproof preferred), vehicle shuttle, day and evening educational programs and entertainment as scheduled. Sojourn T-shirts are complimentary for each sojourner in adult sizes S-M-LXL-XXL. Please bring a water bottle for use at water stops. From Schuylkill Haven to Philadelphia, discover Americas Hidden River, Pennsylvanias first Scenic River.

general itinerary for the week


Programs and presentations will be on recreation in the heritage area including fly fishing, hiking, biking, paddling and more.
PRe-SOjOuRnFRidAY, june 1, 2012 4-8 P.M. CHeCK-in AT SCHuYLKiLL HAven iSLAnd PARK Dinner is on your own. Details about special activities for this evening will be provided. dAY 1SATuRdAY, june 2, 2012 15.5 MiLeS: SCHuYLKiLL HAven TO PORT CLinTOn There will be a lunch and program at Auburn Dam. We will then portage around the dam and continue to Port Clinton for dinner and an evening program. dAY 2SundAY, june 3, 2012 18.5 MiLeS: PORT CLinTOn TO jiM dieTRiCH PARK We will portage around Kernsville Dam. There will be lunch and a program at the Peter Yarnell Park. We will continue on to Jim Dietrich Park for dinner and an evening program. dAY 3MOndAY, june 4, 2012 16.3 MiLeS: jiM dieTRiCH PARK TO GibRALTAR Following breakfast well paddle through Kellys Rapids (an alternate route is available). There will be lunch and a program at Reading Riverfront Park and dinner and an evening program at Gibraltar. dAY 4 TueSdAY, june 5, 2012 13.9 MiLeS: GibRALTAR TO POTTSTOwn After leaving Gibraltar there will be a water stop at the Union Township boat landing. Then lunch and program at Morlatton Village followed by a dinner and evening program at Pottstown Riverfront Park dAY 5wedneSdAY, june 6, 2012 17.8 MiLeS: POTTSTOwn TO MOnT CLARe LOCK 60 There will be lunch and a program at the Royersford Victory Park and dinner with an evening program at Monte Clare, Lock 60 dAY 6THuRSdAY, june 7, 2012 14 MiLeS: MOnT CLARe TO weST COnSHOHOCKen The morning will start on the canal. After a quick portage to the river. Then paddle to Valley Forge National Park for a water stop. Then on to Upper Merion Boat House where there will be lunch and a program. There will be a dam portage at the Norristown Dam and then to dinner and a program at West Conshohocken dAY 7FRidAY, june 8, 2012 16 MiLeS: weST COnSHOHOCKen TO PHiLAdeLPHiA After bidding adieu to the folks at West Conshohocken, we portage our final dam at Flat Rock. Lunch and a closing program is at the Philadelphia Canoe Club. Our final take out will be Lloyd Hall at Boat House Row. The vehicle shuttle will take place from Lloyd Hall to W. Conshohocken, followed by a final shuttle to Schuylkill Haven. Contact Cindy Kott @ 484-945-0200 to take advantage of the final shuttle to Schuylkill Haven.

HAMBURG

LEESPORT

READING

Riverfront Park, POTTSTOWN

PHOENIXVILLE NORRISTOWN

484-945-0200 www.schuylkillriver.org

SCHUYLKILL RIVER SOJOURN 2012


ReGiSTRATiOn

general information and Policies


CLOTHinG
Information about clothing, boats and items to bring along on the river and for camping will be available on-line. If you dont have e-mail, we will mail this information.

There is no online registration. Print out these forms, and complete the REGISTRATION FORM. We will also need each participant to complete the CONFIRMATION FORM, ACA WAIVER for Adult and/or Child, CANOE SUSQUEHANNA WAIVER AND CANOE SUSQHEHANNA MEDICAL FORM. Carefully review and sign all the forms and all the waivers. and mail it to SRGA, 140 College Drive, Pottstown, PA, 19464. Your registration form and payment must be received by May 11, 2012. The sooner you register the better, because the first two days of the Sojourn fill up VERY quickly. Registration is limited and on a first-come, firstserve basis, including full-trippers. To ensure the safest possible trip, we can only accommodate 100 people on the river each day. This limit is set by our safety officers.

Pottstown: Kellys Canoe & Kayak Center 610-369-1778 Philadelphia: Philadelphia Canoe Club www.philacanoe.org Berks County: Keystone Canoe Club www.keystonecanoeclub.com

CAnOeS, KAYAKS And RenTALS

You must provide your own kayak or canoe, type 3 life vest and paddles. If renting, you are responsible for your own rental arrangements, which will include type 3 life vest(s) and paddles. Canoe or kayak rentals are available through: Doug Chapman owner of Kellys Canoe & Kayak, Gilbertsville, PA 610-369-1778, Please make sure you are registered for the Schuylkill Sojourn before making your equipment rentals. A maximum of 2 adults and one child is permitted per canoe. Special exceptions are possible at the discretion of the safety leaders.

SOjOuRn POLiCieS

No glass containers allowed on the river. ALL participants must attend the daily MAndATORY safety briefing conducted before launching. Skills instruction will be available. Participants must adhere to the safety guidelines presented. Participants must wear a USCG approved Type 3 personal flotation device (PFD) at all times. Participants under the age of 18 years are the responsibility of, and must be accompanied by, a parent or guardian. Children must be able to swim and weigh at least 40 pounds to be properly fitted with a PFD. All participants must sign a liability waiver. Parents must sign for children under 18 years of age. Directives of the Safety Officers must be followed in all situations. No pets allowed. Alcoholic beverages are not allowed on the river, in municipal parks and will not be served at Sojourn-sponsored events. Organizers and safety officers of the Schuylkill River Sojourn reserve the right to take anyone off the river who is either physically challenged by paddling, the amount of paddling required, or in a craft that does not fit or is beyond their skill level.

AFTeR we ReCeive YOuR ReGiSTRATiOn


We will e-mail you a confirmation message. 7-10 days before June 2 youll receive an e-mail link to the Daily Plan Sheets with each days itinerary, maps, and other helpful information. Share the Daily Plan Sheets link with family and friends so they can follow your progress down the river. If you dont have e-mail, we will mail your information.

equiPMenT And CAR SHuTTLe

Every morning your gear is loaded onto a shuttle trailer, and is transported to that evenings campsite. At the end of the day, after everyone is off the river, a shuttle bus will return to that mornings launch site for people who need to move their cars. To enjoy the continuity of the trip, leave the car at home! A friend can drop you off and pick you up at the end of your trip, or take the final shuttle back to Schuylkill Haven.

SOjOuRn CHeCK-in

When you join the Sojourn, you must check-in (look for the Sojourn flag). You will receive a Sojourn sticker for your boat and your meal ticket/name tag.

CAMPinG

On-RiveR inFORMATiOn

You must provide your own camping equipment: tent, sleeping bag, drop cloth, tarp, etc. Many of the camping spots are in municipal riverfront parks with primitive facilities. We make every effort to provide you with the necessary amenities for pleasant camping. Showers are available at some stops. Cooking equipment is not allowed. At some of the campsites tents will be close together. Please be courteous of your neighbors, quiet time starts at 10 p.m. If you prefer not to camp, a list of nearby lodging is available. Alternate lodging arrangements are your responsibility. Campers, motor homes and car camping are not permitted.

During the day the safety leaders and designated safety volunteers guide the group down the Schuylkill River. The group is expected to stay together, and at times will be required to stop and wait for the entire group to move through a narrow area. Every paddler must stay in front of the last safety boat (sweep boat). Along the Schuylkill River there are portages. At these times everyone is encouraged to help other Sojourners carry their boats around the obstruction. Portage wheels are allowed as long as they fit securely and safely inside your own boat.

LATe Fee: Registrations received after May 11 will be charged a $10 late fee. CAnCeLLATiOn POLiCY: Refunds will be given, minus a $25 processing fee, if request is received by May 25. no refunds can be given after May 25 because final numbers have been given to meal and other service providers.

PRe-SOjOuRn PAddLinG

MeALS

If youve never paddled on moving water, it is recommended you receive some instruction or experience. If you need a paddling lesson or want to brush up on your skills, contact a Canoe or Kayak club in your area.

Meals are included in registration. Vegetarian meals (lacto-ovo) are available, but expect pasta and cheese dishes to accommodate vegetarian diets.

484-945-0200 www.schuylkillriver.org

SCHUYLKILL RIVER SOJOURN 2012


Any questions, call 484-945-0200 or e-mail info@schuylkillriver.org. Mail completed original forms and payment to: Schuylkill River Heritage Area 140 College Drive Pottstown, PA 19464 Registration closes on May 11, 2012 PLEASE PRINT LEGIBLY AND NEATLY
1. Name: ______________________________________________ Age: _____ ACA member #: _______________ o vegetarian meals 2. Name: _____________________________________________ Age: _____ ACA member #: _______________ o vegetarian meals 3. Name: _____________________________________________ Age: _____ ACA member #: _______________ o vegetarian meals 4. Name: _____________________________________________ Age: _____ ACA member #: _______________ o vegetarian meals Main Contact Street Address: ________________________________________________ Daytime Phone: (________)_______________ City: __________________________________State: _______ Zip: __________ E-mail: ____________________________________ Other registrants e-mail(s): o I/we are renting canoes or kayaks. (you are responsible for making your rental arrangements)
T-SHIRTS ARE COMPLIMENTARY (One shirt per participant) Indicate the number of shirts in Adult Sizes: S_____ M _____ L _____ XL _____ XXL _____

Adult Day 1 Saturday Day 2 Sunday Day 3 Monday Day 4 Tuesday Day 5 Wednesday Day 6 Thursday Day 7 Friday FULL TRIP June 2 June 3 June 4 June 5 June 6 June 7 June 8 _______ x $85 _______ x $85 _______ x $85 _______ x $85 _______ x $85 _______ x $85 _______ x $75 _______ x $550

Children 15 & under _______ x $65 _______ x $65 _______ x $65 _______ x $65 _______ x $65 _______ x $65 _______ x $55 _______ x $420 SUBTOTAL

TOTALS $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $___________

Become a Schuylkill River Heritage Area Member today for $55.00 and save 10% $____________ SRHA Members deduct 10% from SUBTOTAL only ($ ___________) TRIP GRAND TOTAL
Non-ACA members must pay an event insurance fee Adult ______ x $5 Children _______ x $5 After May 11, per person late fee $10

$___________
$ ___________ $ __________

TOTAL AMOUNT ENCLOSED $ __________


CANCELLATION POLICY: Refunds will be given, minus a $25 processing fee, if request is received by May 25. We cant give refunds after May 27 because all meals and services will have been ordered PAYMENT METHOD: o Check enclosed (payable to Schuylkill River Greenway Assn.)
Billing Address (if different from primary address above): ____________________________________________________________________________________________________________________ Signature: ________________________________________________________________________________

o Charge my Visa/Mastercard

Name on Card: _______________________________________ Card #: _______________________________________ exp. date: ___________

Schuylkill River Sojourn 2012 CONFIRMATION FORM


Please complete all sections Name: of this form. Originals of this form and waivers must be Address: City: received by
Please Print Neatly
Date of Birth: State: Zip:

May 18, 2012

E-mail address*:

Phone eve.: Schuylkill River Greenway Assn. Phone day: 140 College Drive We must have this completed form by May 18, 2012 for you to participate in the Sojourn or your information will not be included on the Sojourn Participant List. Pottstown, PA 19464
484-945-0200

o Check here if you do not want your information on Participant List or shared with other Sojourners

* All correspondence after registration will be by e-mail, including how to download nal information & maps. If no e-mail is available, put N/A on line.

I am registered for the following days: o Entire Trip o Saturday o Sunday

o Monday

o Tuesday

o Wednesday

o Thursday

o Friday

o I am bringing my own boat o Canoe o Kayak Length: ____________ Material: _________________________________ o I am renting a boat (you are responsible for your rental arrangement) During my evenings with the Sojourn I plan to: o Camp o Go Home/to friends house o Stay at a hotel/motel/inn

Experience Information
I rate my paddling ability on moving water as: o No experience o Beginner o Intermediate o Advanced I have certication for: o Advanced Medical Training: _____________________________________________________________ o Paddling (explain): ________________________________________________________________________________________ o Other: __________________________________________________________________________________________________ o I am willing to serve as a Safety Ofcer. (Safety Ofcer selection and need is at the discretion of Canoe Susquehanna principals). State experience: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________
The information provided is for the SRGA and Canoe Susquehanna in case of an emergency

Emergency Information

Physician Name: ______________________________________________________ Physician Phone: ______________________ Health Insurance: __________________________________________ Policy #: _________________________________________

I hereby agree to abide by all rules and policies of the Schuylkill River Sojourn and recognize that I may be prohibited from activities if I fail to comply with the rules and policies. I authorize Schuylkill River Greenway Association, Canoe Susquehanna (Allan and Betsy Quant), HRO Adventures, LLC and any of the Schuylkill River Sojourn Planning Committee members to obtain emergency medical treatment for me, if necessary. I also give permission for my photograph to be taken during the Schuylkill River Sojourn activities and for the organizers of the Schuylkill River Sojourn, and Schuylkill River Greenway Association specically, to use my photographic image in commercial or noncommercial publicity for the event, for the Schuylkill River Greenway Association and for the Schuylkill River.

Medical Release and Photo Waiver

___________________________ Date

_______________________________________________________________________ Signature (if under 18, must have signature of parent or guardian)

If this is your rst Schuylkill River Sojourn, how did you hear about the sojourn? o Previous SR Sojourn(s) o Friends/Family o Newspaper o Web Page o Other: ____________________________________

All participants in ACA-insured activities must be ACA members in one of the following categories (choose one):
I am currently an ACA member. My member number appears below. (Check here if renewing with this form ) I would like a one-year Senior (62+) or Student Membership for $25 (under 18, or under 23 with copy of student ID) I would like a one-year ACA Paddle America Club Membership for: (check & circle one) Individual $30 | Family (2 adults + minors) $40 I would like an ACA Introductory Membership for $15 (Six month membership with benefits, including a Rapid Media magazine) I would like a one-year ACA Membership for: (check & circle one) Individual $40 | Family (2 adults + minors) $60 I would like an ACA Event Membership for $5 (one activity membership, no member benefits)

AMERICAN CANOE ASSOCIATION MEMBERSHIP FORM

AMERICAN CANOE ASSOCIATION ADULT WAIVER & RELEASE OF LIABILITY

READ BEFORE SIGNING

IN CONSIDERATION of being permitted to participate in any way in the American Canoe Association, Inc. sports and recreation program and related activities (Activities) I, for myself, my personal representatives, assigns, heirs, and next of kin: 1. ACKNOWLEDGE, agree, and represent that I understand the nature of paddlesports and related activities and that I am qualified, in good health, in proper physical condition to participate in such activity and willingly agree to comply with the stated and customary terms and conditions of participation. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity. If I decide to leave early and not complete the trip as planned, I assume all risks inherent in my decision to leave. 2. FULLY UNDERSTAND that: (a) Paddlesports and related ACTIVITIES INVOLVE RISKS AND DANGERS OF DAMAGE TO PERSONAL PROPERTY AND SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity. 3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the American Canoe Association, Inc., its Paddle America Clubs, affiliated clubs and organizational affiliates, their respective ACA certified instructors, certified instructor trainers, and certified instructor trainer educators, administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, INJURIES, DAMAGE TO PROPERTY, OR OTHER DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
Name (print) Street Address City Email Date Name / Description of Activity or Event Sponsoring Club / Organization
Rev 02/2011

Date of Birth

ACA # (if any)

State Phone Adult Signature

Zip

Activity Date

I am currently an ACA member. My member number appears below. (Check here if renewing with this form ) I would like an ACA Introductory Membership for $15 (Six month membership with benefits, including a Rapid Media magazine)

All minor participants in ACA-insured activities must be ACA members in one of the following categories (choose one):
would like a one-year Student Membership I(Under 18, or under 23 with copy of student for $25 ID) I would like an ACA Event Membership for $5 (One activity membership, no member benefits)

AMERICAN CANOE ASSOCIATION MEMBERSHIP FORM

AMERICAN CANOE ASSOCIATION MINOR WAIVER & RELEASE OF LIABILITY


IN CONSIDERATION of being permitted to participate in any way in the American Canoe Association, Inc. sports and recreation program and related activities (Activities) I, for myself, my personal representatives, assigns, heirs, and next of kin: 1. ACKNOWLEDGE, agree, and represent that I understand the nature of Paddlesports and related Activities and that I am qualified, in good health, in proper physical condition to participate in such Activity and willingly agree to comply with the stated and customary terms and conditions of participation. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity. If I decide to leave early and not complete the trip as planned, I assume all risks inherent in my decision to leave. 2. FULLY UNDERSTAND that: (a) Paddlesports and related ACTIVITIES INVOLVE RISKS AND DANGERS OF DAMAGE TO PERSONAL PROPERTY AND SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of the minor in the Activity. 3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE American Canoe Association, Inc., its Paddle America Clubs, affiliated clubs and organizational affiliates, their respective ACA certified instructors, certified instructor trainers, and certified instructor trainer educators, administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, INJURIES, DAMAGE TO PROPERTY, OR OTHER DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim. MINOR PARTICIPANT: I, THE MINOR PARTICIPANT, HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
Minor Name (print) Minor Street Address Minor City Date Minor State Minor Signature Minor Zip Minor Date of Birth Minor Phone Minor Email ACA # (if any)

READ BEFORE SIGNING

PARENT OR GUARDIAN: I, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF PADDLESPORTS AND RELATED ACTIVITIES AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR'S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.
Parent/Guardian Name (print) P/G Street Address P/G City Date Activity Description P/G State P/G Zip Parent/Guardian ACA # (if any) P/G Phone P/G Email

Parent / Guardian Signature Sponsoring Org. Activity Date

MINOR WAIVER

REVISED 01/12

Release of Liability
Read before signing. Please print neatly.
Print Name

www.Paddle Happ 888-524-769 y.com 2

In consideration of being allowed to participate in this Canoe Susquehanna LLC program, its related events and activities, I, _________________________________________, the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of Canoe Susquehanna LLC immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Canoe Susquehanna LLC, their owners, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used for the activity (Releasees), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law; and, 5. I authorize Releasees to provide or obtain for me such medical care as they consider necessary and appropriate, and I agree to pay all cost associated with such care and related transportation; and, 6. I hereby give permission for my photo to be taken during activities with Canoe Susquehanna LLC and for said photographs to be used in commercial and non-commercial activity. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. _________________________________________
Participants Signature

Print Name

_________________________________________ ___________________ ______

Age

______ ______________
Date Signed

_______________________________________________________
Address

City

State

______________
Zip Code

_______________________________________________
Email Address

Include your email address to receive a link to pictures taken on the trip!

For Parents/Guardians of Participants of Minor Age


(Under age 18 at time of registration)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child, and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor childs involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. _________________________________________
Parent/Guardians Signature

Print Name

_________________________________________

Date Signed

______________

Pleaseprintneatly.Onepersonper form.Medicalinformationwillbe treatedasconfidential.Information willonlybesharedwithprogram staffandmedicalpersonnel.

___________________________________ ___________________________________
LastName

FirstName

___________
Age

Height

___________

Weight

___________

Male Female

MedicalHistory

MedicalandEmergencyInformation

Markanyandallmedicalconditionsyouhaveorhavehadinthepast.

Program: 2012 Schuylkill River Sojourn

BleedingorClottingProblems Diabetes Dislocations,Fractures,BoneProblems EatingDisorders

HeartorBloodPressureProblems JointProblems MentalHealthProblems Neck,SpineorBackProblems

PhysicalDisability Pregnancy RespiratoryProblemsorAsthma SeizuresorEpilepsy

Describeallmedicalconditions(listedaboveorotherwise).

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Describeallrecentsurgeries,injuriesandillnesses.

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

888-524-7692

Allergies
Listallknownallergies.Includefood,medication,insect,topical,andallotherallergiesyoumayhave.Ifapplicable, describethesymptomsyouexperiencewhenexposedtoeachallergenandwhenyoulasthadareaction.

www.PaddleHappy.com

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Medications
Listallprescriptionandnonprescriptionmedicationsyoutake.Indicatewhyyoutakeeach,thedosageandfrequency. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Canoe Susquehanna LLC

EmergencyContacts
Listtwopeople(notonthetrip)whocouldbecontactedinthecaseofamedicalemergency.
Name

___________________________ ____________________ ____________________ __________________


PhoneNumber AlternatePhoneNumber Relationship

___________________________ ____________________ ____________________ __________________ Name PhoneNumber AlternatePhoneNumber Relationship

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