Kayaking Program Digital Waivers – OceansOfHopeFoundation.org

Essential Eligibility Criteria (EEC) / Medical Self-Evaluation Form / Insurance Waiver / Release of Liability Waver & Media Release Form

Name *

First

Middle

Last

Name *

First

Middle

Last

Email

Height *

Weight *

Date of Birth *

Can you seal your airway passage while under water? *

Yes
No
Partly
I Don't Know

Do you require any type of external neck support *

Yes
No
Partly
I Don't Know

Are you able to wear a properly fit life jacket (PFD) *

Yes
No
Partly
I Don't Know

Please describe your swimming ability: *

Please describe your canoeing / kayaking / rafting / other paddlesports experience. *

Allergies? *

Yes
No

Heart Disease? *

Yes
No

High Blood Pressure? *

Yes
No

Dislocations? *

Yes
No

Do you get cold easly? *

Yes
No

Allergic to insect bites or stings? *

Yes
No

Diabetes? *

Yes
No

Asthma? *

Yes
No

Are you pregnant? *

Yes
No

Allergic to any medications? *

Yes
No

Back Problems? *

Yes
No

Muscle spasms? *

Yes
No

Are you greatly affected by heat? *

Yes
No

Are you taking medications? *

Yes
No

Any side effects of medication such as sun sensitivity, increased thirst or fatigue? *

Yes
No

If you answered YES to any of the questions above please explain below:

Do you have a disability? If yes, please describe:

Do you have mobility impairment? If yes, please describe:

Do you have sensory impairment (sight, sounds or sensation)? If yes, please describe:

So that we can better understand your needs, please list any medical, physical, physical, psychological or emotional issues not mentioned above:

In case of Emergency - Please contact: *

First

Last

Day Phone# *

Other Number:

Relation:

Name *

First

Middle

Last

Participant/Volunteer's Name *

First

Last

Phone Number: *

Email:

Date of Birth: *

Male/Female *

Male
Female

Height: *

Weight: *

Emergency Contact: *

Emergency Contact Phone: *

Participant Name *

First

Middle

Last

Parent/Guardian's Name

First

Middle

Last

Name *

First

Middle

Last

Enter Today's Date: MM/DD/YYYY *

Phone