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2015 Registration For Club Use Only: Still Need:____ BV___________ _____ Photo________ _____ Transfer______ Club Page, Waivers due before get in wa’a Dues Paid __________________ KEAUKAHA CANOE CLUB BV’s, Transfers due April 11, 2015 Dues to be paid by April 25, 2015‐you will be registered when your dues are paid Please print or write clearly Paddler Name (print) _____________________________________________________________________
Sex: M F Current Age_______ Birthdate_______________________ Nickname, if any: __________________________________ Email: ____________________________________________________ Home phone:____________________________________ Address: _________________________________________________ Cell phone:______________________________________ City: ____________________________________Zip: _____________ Work phone:_____________________________________ Can you swim? Yes No
Is this your first year of paddling? Occupation or school:____________________________________________ Yes No If no, name of club where last registered if not Keaukaha __________________________________________________________
If you are registered at another club, you will need to obtain a transfer. *********************************************************************************************************** In case of emergency, please call: ________________________________________________________________________________ Relationship:_______________________________________________ Phone number: ___________________________________ DUES: Na Opio: ages 12‐18 (Your dues of $45 are paid by club fundraisers) Adults: $90 ($80 if paid by April 25, 2015)
(Includes Long Distance)
First time adult paddlers: $95 ($85 if paid by April 25, 2015) (the extra $5 is for HCRA ID card charge) *********************************************************************************************************** NEW PADDLERS NEED TO TURN IN BIRTH VERIFICATION Acceptable documents are: a readable copy of your driver’s license, birth certificate, passport, state id. ************************************************************************************************************ For minor paddlers only: Mother:________________________________________________ Phone______________________________________________ Father: ________________________________________________ Phone _______________________________________________ Guardian/Hanai _________________________________________ Phone________________________________________________ Hawaiian Canoe Racing Association Insurance Program
Canoe Club:
Keaukaha
Canoe
Club
Adult and Minor Waiver and Release of Liability
___________________________
January 1, 2015 to December 31, 2015
In consideration of being allowed to participate in any way in the Hawaiian Canoe Racing Association and its
member organizations’ athletics/sports programs, and related events and activities, the undersigned:
1. Agree that prior to participating, they each will inspect the facilities and equipment to be used, and if
they believe anything is unsafe, they will immediately advise their coach or supervisor of such
condition(s) and refuse to participate.
2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk
of serious injury, including permanent disability and death, and severe social and economic losses which
might result not only from their own actions, inactions or negligence, but the action, inaction or
negligence of others, the rules of play, or the condition of the premises or of any equipment used.
Further, that there may be other risks not known to us or not reasonably foreseeable at this time.
3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury,
permanent disability or death.
4. Release, waive, discharge and covenant not to sue the Hawaiian Canoe Racing Association, its member
associations, its affiliated clubs, their respective administrators, directors, agents, coaches, and other
volunteers or employees of the organization, other participants, sponsoring agencies, sponsors,
advertisers, and if applicable, owners and leasers of premises used to conduct the event, all of which are
hereinafter referred to as “releasees”, from demands, losses or damages on account of injury, including
death or damage to property, caused or alleged to be caused in whole or in part by the negligence of the
releasee or otherwise.
The undersigned custodial parent or legal guardian acknowledges that he/she is also signing this release on
behalf of the minor participant, that he/she is waiving certain rights on behalf of the minor participant that the
minor participant otherwise may have and that the minor participant shall be bound by all of the terms of this
release. By signing this waiver and release without a parent’s or guardian’s signature, the participant represents
he/she is at least 18 years of age, or, if signing as the parent or guardian of the participant, signer represents they
are the custodial parent or legal guardian of the minor participant.
THE UNDERSIGNED HAVING READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND
THAT THEY HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT
VOLUNTARILY.
Paddler Name (print) _________________________________________________________ Sex □ F □ M
Street Address _________________________________________________ Birthdate __________________
HI
City __________________________________ State ___________________
Zip Code __________________
Phones: Home ____________________ Work ____________________ Cell/Pager ____________________
Email Address ____________________________________________________________________________
In an emergency, contact ______________________________________ Phone _______________________
If a minor, Printed Name of Custodial Parent or Guardian _________________________
Signature:_______________________________ Date ____________
(Adult
Paddler or Minor’s Guardian)
Keaukaha Canoe Club Waiver and Release of Liability
Hawaiian canoe racing is a wonderful sport. Before you participate, consider the
hazards! This form is a waiver of your legal rights if you are injured. This form consists of
two pages. Read both pages carefully.
I agree that I am signing this form in consideration of being allowed to participate in the
athletics, sports programs and all related events and activities of the Keaukaha Canoe Club and the
Hawaiian Canoe Racing Association and its member organizations (together called "the
Organizations"). I agree that I am signing this form only after I have carefully read it and that I
understand it.
By my initials in each of the spaces below, I agree:
Initials: ____
I understand that canoe paddling, canoe racing and other activities of the
Organizations involve strenuous physical exercise, and that I am qualified, in good
health, and in proper physical condition to participate in such activities. I am
capable of treading water and I can swim adequately to take care of myself in the
ocean.
Initials: ____
I understand that every paddler is responsible for investigating his/her own
medical condition with his/her own physician. I agree that I will not place
any responsibility on the Organizations to investigate the medical
condition(s) of myself or other paddlers.
Initials: ____
I will notify the President of the Keaukaha Canoe Club, my coach and my fellow
paddlers if I have, or if I develop, any physical problems or conditions of any
sort- including heart conditions -that may affect my ability to participate without
posing a danger to my health or safety or the health or safety of others.
Initials: ____
I agree and understand that there are risks in participating in canoe Paddling
and canoe racing and other activities of the Organizations, and I understand
that these risks include risks of serious physical injury and/or death which may
result from:
•
Risk of drowning, which may happen if the canoe capsizes, if I fall
out of the canoe, if I am knocked unconscious in the water, or from
many other causes.
•
Risk of injuries from my body coming into contact with a
canoe, or another paddler, or a paddle, or other equipment, or
automobiles and canoe trailers, or other causes.
•
Risk of injuries from exposure to variable extremes of weather
and ocean conditions, including currents, swells, waves, and
marine life, and potential extremes of heat and cold.
•
Risk of illness if I am not physically able to participate in
activities involving strenuous physical exercise.
Initials:____
I understand that there are many other risks that may arise from conditions,
situations or activities of which I am presently unaware.
Initials: ____
I voluntarily assume these and all risks and I accept personal responsibility
for any damages if I suffer any injury, including permanent disability or
death.
Initials: ____
I release, waive, discharge and promise that I will not sue the Organizations,
or any of their members, their respective administrators, directors, agents,
coaches, and other volunteers or employees of these organizations, other
participants, sponsoring agencies, advertisers, and if applicable, owners and
lessors of premises used to conduct events, all of which are hereafter referred to
as "Releasees", from demands, losses or damages on account of injury, including
death, or damage to property, caused or alleged to be caused in whole or part by
the negligence or other wrongful conduct whatsoever of the Releasees.
Initials: ____
In signing my name below, I acknowledge and agree that I have read all of
the above statements carefully and I understand that by signing this
document I am giving up substantial rights that I otherwise would have, and I
am signing this document voluntarily and as my own free choice.
Print Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Signature:
Date: -------------------
-------------------------------------
If Minor:
Printed Name of Custodial Parent/Guardian: ------------------------ -------------Signature of Custodial
Parent/Guardian:
----------------------------------------
Keaukaha Waiver Page 2 of 2
Date
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