FORT LANGLEY YOUTH ROWING SOCIETY

Please provide all requested information. Note that all areas must be filled in to complete registration

Participants Name

Parent Name

Address

City

Postal Code

Parents Email (used to contact)

Rowers Email

Home Phone Number

Cell Phone Number

Birth Date

Sex

Male
Female

Please Select the TOP 3 WEEKS and Time of preferred session

Week 3 July 10 - 14 Time 10:30 - 12:30
Week 3 July 10 - 14 Time 1:00 - 3:00
Week 4 July 17 - 21 Time 10:30 - 12:30
Week 4 July 17 - 21 Time 1:00 - 3:00
Week 5 July 24 - 28 Time 10:30 - 12:30
Week 5 July 24 - 28 Time 1:00 - 3:00
Week 6 July 31 - August 4 Time 10:30 - 12:30
Week 6 July 31 - August 4 Time 6:00 - 8:00pm
Week 7 August 8 - 11 Time 10:30 - 12:30
Week 7 August 8 - 11 Time 1:00 -3:00
Week 8 August 14 - 18 Time 10:30 - 12:30
Week 8 August 14 - 18 Time 1:00 - 3:00
Week 9 August 21 - 25 Time 10:30- 12:30
Week 9 August 21 - 25 Time 1:00 - 3:00
Week 10 August 28 - Sep 1 Time 10:30 - 12:30
Week 10 August 28 - Sep 1 Time 1:00 - 3:00
FALL - Sept 16 & 17th 9:00am - 12:00

What is your most preferred Week and Time

Program fee: $200.00 (includes Taxes and Rowing Canada/Rowing BC Membership Fees). $160.00 for 4 day week. $120 for FALL session Rowers who have completed a previous Learn to Row course receive 20% off. Receive 10% off your registration if you sign up 2 friends in the same week. Cheques are made to FLYRS. Following completion of the Learn to Row course, youth are eligible to row for the remainder of the summer at a cost of $75 per week.

Notes:

- RCA Membership – Rowing Canada provides general liability and support services to rowing clubs in Canada. Annual membership is required in order to participate in Fort Langley Youth Rowing Society activities. - Payment: Please make cheques payable to Fort Langley Youth Rowing Society. Registration, Waiver, Medical Information Form, Safety Guidelines and payment are to be mailed to The Registrar, Fort Langley Youth Rowing Society, P.O. Box 27, STN Fort Langley, Langley, B.C. V1M 2R7 - Privacy Statement: All personal information given by participants will only be used for administration and regular communication with respect to the rowing programs. Your information will not be sold or given to anyone else with commercial intentions or otherwise.

EMERGENCY CONTACT INFORMATION

Parent/Guardian 1

Telephone: Day

Telephone: Cell

Email

Parent/Guardian 2

Telephone: Day

Telephone: Cell

Email

Emergency Contact's Name: (Other than parents)

Relationship to Rower

Phone #

Cell Number

MEDICAL INFORMATION

Care Card #

Date of last tetanus immunization

Family Physician

Telephone

Medications taken on a regular basis

Allergies

Medical conditions currently under treatment

Pre-existing physical conditions under treatment

Contact Lenses or Glasses

yes
no

Any other notes that may be of assistance to coaches and/or chaperones:

I hereby give permission for the Fort Langley Youth Rowing Society to be responsible for providing medical supervision and treatment of my child if required.

Yes, I agree to these Terms
No, I do not agree to these Terms

RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

IN CONSIDERATION of and for the Fort Langley Youth Rowing Society (“FLYRS”) permitting me to participate in rowing programs, rowing activities, events and any other activities on water or on land that FLYRS organizes, sponsors, attends or otherwise participates in (the “Rowing Activities”), and to use the facilities and equipment available through FLYRS, I, the undersigned, for myself, and, in the event of my death or incapacity, my heirs, next-of-kin, executors, administrators and representatives, agree with FLYRS, its directors, officers, agents, employees, coaches, contractors, members, volunteers, other participants in the Rowing Activities, regatta organizers, sponsors, advertisers and owners and lessors of any premises on which any of the Rowing Activities takes place (collectively the “Releasees”) as follows: I WARRANT AND REPRESENT, both now and throughout my participation in the Rowing Activities, that: 1. I understand that rowing shells are unstable and not designed for use in rough water conditions and that rowers’ face away from the direction in which they are rowing. I understand the nature of the Rowing Activities, whether occurring on water or land, and that the Rowing Activities involve danger and the risk of serious bodily injury, including but not limited to partial or permanent disability; paralysis; death; and other risks, such as social or economic loss, either unknown or not foreseeable now (collectively the “Risks”). I further understand that the Risks may arise from dangers including, but not limited to, the physical exertion involved in the Rowing Activities; carrying boats; placing boats in and lifting them out of the water and storage locations; collision with another boat, or a floating or stationary object; equipment malfunction; capsizing; swamping in waves caused by passing vessels or adverse weather; hypothermia; hyperthermia; and drowning. 2. I understand that my own action or inaction, the action or inaction of others, the conditions in which the Rowing Activities take place, or the negligence of one or more of the Releasees may expose me to danger and the Risks. 3. I am in good health and am medically fit for participation in the Rowing Activities. Without limiting the generality of the forgoing, I do not suffer from a heart condition or other ailment that participation in the Rowing Activities could aggravate. Further, either I am able to swim 50 meters immediately after which I can tread water for 10 minutes, or I hold the Bronze Cross/Medallion in swimming, or both. I AGREE THAT: 4. I will at all times obey all safety rules established by FLYRS. 5. I am responsible for my own safety and will participate in the Rowing Activities within the limits of my abilities. At any time I believe any of the Rowing Activities or the conditions in which that activity is taking place are unsafe or beyond my abilities, I will immediately cease to participate in that activity. 6. I fully accept and assume the Risks and full responsibility for all injury, damages, loss and costs I may suffer arising from my participation in any of the Rowing Activities. 7. I will indemnify, save and hold harmless the Releasees from any and all liability for any property damage or personal injury to the Releasees or any of them, or to any third party, resulting from my participation in the Rowing Activities. 8. If, despite this Agreement, I or anyone on my behalf makes a claim against the Releasees or any of them, I will indemnify, save and hold harmless the Releasees and each of them from any liability, claims, demands, loss, damages or costs which they or any of them may incur as a result of that claim. I HEREBY WAIVE ANY AND ALL CLAIMS THAT I HAVE OR IN THE FUTURE MAY HAVE AGAINST THE RELEASEES AND RELEASE AND FOREVER DISCHARGE THE RELEASEES and each of them from any and all liability for any loss, damage, expense or injury, including death, that I or any of my next-of-kin may suffer arising from my participation in the Rowing Activities due, or alleged to be due, to any cause whatsoever, in whole or in part, including but not limited to negligence, breach of contract, breach of any statutory or other duty of care, including any duty under the Occupiers Liability Act, of the Releasees or any of them, and further including but not limited to failure on the part of the Releasees or any of them to safeguard and protect me from the Risks and the dangers of the Rowing Activities, and negligence in any rescue operations any of them may undertake.

I have read this Agreement. I fully understand its terms and that I have given up substantial rights by clicking this box. I intend it to be a complete and unconditional release of all liability.

Complete this part ONLY if Participant is under 19 years of age

I, the parent and/or legal guardian of the Minor Participant, understand the nature of rowing and the Rowing Activities and the Minor Participant’s experience and abilities. I believe that the Minor Participant is medically fit and able to participate in the Rowing Activities without limitation. I have read, understand and agree with the terms of the foregoing Agreement and will ensure that the Minor Participant fulfills the Participant’s obligations thereunder, and I HEREBY RELEASE AND FOREVER DISCHARGE THE RELEASEES and each of them from any and all liability, claims, demands and costs for any loss, damages, expenses or injury, including death, that the Minor Participant or any of the Minor Participant’s next-of-kin may suffer due, or alleged to be due, to any cause whatsoever, in whole or in part, including but not limited to negligence, breach of contract, breach of any statutory or other duty of care, including any duty under the Occupiers Liability Act, of the Releasees or any of them, and further including but not limited to failure on the part of the Releasees or any of them to safeguard and protect the Minor Participant from the Risks and the dangers of the Rowing Activities, and negligence in any rescue operations any of them may undertake. If, despite this Agreement, I, the Minor Participant, or anyone on the Minor Participant’s behalf makes a claim against the Releasees or any of them, I will indemnify, save and hold harmless the Releasees and each of them from any liability, claims, demands, loss, damages or costs which they or any of them may incur as a result of that claim.

I have read the above terms and, with clicking this box, agree to the terms set out above.

PHOTO WAIVER

I, the parent and/or legal guardian of my child, do hereby grant permission for the Fort Langley Youth Rowing Society to photograph and to publish the photographs of my child on the Fort Langley Youth Rowing Society website and in related Fort Langley Youth Rowing Society promotional brochures, posters, and videos for the purpose of promoting the Fort Langley Youth Rowing Society. I also give permission for photos of my Child to be used in conjunction with newspaper articles submitted to or written by news media outlets. I hereby waive all rights of privacy and/or compensation for my Child which he/she may have in connection with the use of his/her photograph or likeness in, or in connection with, said website, still photography, or film and any use to which the same material may be put, applied or adapted by the Fort Langley Youth Rowing Society in connection with the promotion of the Fort Langley Youth Rowing Society. I release the Fort Langley Youth Rowing Society from and against any and all claims, liabilities or damages arising out of, or in connection with, my Child’s photographs or likeness being used by the Fort Langley Youth Rowing Society for its promotional activities. I understand that my Child will not be identified by name in any promotional materials without further written consent.

By checking this box, I agree to the terms of the Photo Waiver.
- I do not give Fort Langley Youth Rowing the authorization to use my child’s picture.

FLYRS T-Shirt

Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large

How did you hear about Learn to Row?

Any questions, comments, concerns?