IARVCP 2017 REGISTRATION FORM
Instructions: Save this form to your desktop, fill in all fields, save it again filled out, then attach it to an email and send it to carol-sweeting@iowa-city.org. Questions? Call Carol Sweeting: 319-541-2385. Cleanup date is Saturday September 16, 2017.  Limited free canoes are available, so pre-registration by September 8, 2017 is strongly advised. 
•	You can sign up and participate right up to the date of the event.  Only one person may register per form.  
•	Paddlers under 10 years old as of September 16, 2017 must have prior canoeing experience.  Persons under 18 must be accompanied by parent or guardian.
•	Complete all three (3) pages in their entirety. Double check your form before you send!
•	Water will be provided, but you are responsible for lunch and any other food items you require. It is advisable to bring a personal cooler for your lunch and a reusable water bottle.

Name:       E-mail:      
Address:       City/State/ZIP:      
Phone:       Cell:       Age (if under 18 as of 09/16/2017):            
I will be paddling :  Yes   No
I will be volunteering on land:  Yes   No 

Canoe Use and Ability
Please fill out this section even if you own your own canoe or kayak.  (You may skip this section if you are an on-shore volunteer only.)  For those that do not own their own canoes, there are a limited number of canoes available free of charge with paddles and PFD’s (keyhole life jackets) provided.  
Do you need a canoe? Yes     No, I will be bringing my own Canoe or Kayak 
What is your paddling skill level?  Beginner Intermediate   Experienced 
Do you have a Partner? Yes   No
If Yes, name of partner:      
Do you need a PFD (life jacket)?  Yes    No, I have my own

SAFETY INFORMATION, RELEASE & WAIVER OF LIABILITY
	Safety precautions, recommendations and regulations will be in place at all times.
	
	• Personal Flotation Devices (PFDs – life jackets) are required to be worn at all times  when participants are in a vessel on the water. Children require appropriately-sized PFDs.  It is the responsibility of the participants to supply appropriately-sized PFDs for themselves or to wear one of a limited number of orange “keyhole” PFDs. Alcohol consumption is prohibited.
		
	• Parents/legal guardians and/or authorized adult companions of children under 18 years of age will be responsible the child’s safety. By signing below, the parent/legal guardian of the minor agrees to the terms and conditions of this waiver, and authorizes the designated legal adult named below to be responsible for the minor.  
	
The applicant and parent/legal guardian(s), by signing below, recognize that the program involves some risk and that she/he takes responsibility for all action or injury that may result in participating in Iowa River Cleanup Project (IARVCP). All children under 18 must be accompanied by a parent/legal guardian or authorized adult companion, and must have a parent/legal guardian signature(s) and, if applicable, authorization of an approved adult companion, below. The applicant and parent/legal guardian, by signing below, agree to the following statement: All participants are required to wear an appropriately-sized PFD (personal flotation device) at all times when they are in a vessel on the water.

Are you 18 years old or over?  yes  no 
  
	I,       (applicant name) and       (parent/legal guardian name, if applicable), hereby release, waive, discharge and covenant not to sue the State of Iowa, Iowa Department of Natural Resources, Iowa River Cleanup Project, the City of Iowa City, any canoe outfitter, county or other agencies, partners, cooperating landowners, sponsors and any of the offices, servants, agents and employees of the above-mentioned entities (hereinafter referred to as “RELEASEES”) for any liability, claim and/or cause of action arising out of or related to any loss, damage or injury, including death, that occurs as a result of my participation my child’s participation in IARVCP. 
	I agree to indemnify and hold harmless the RELEASEES whether injury is caused by my negligence, the negligence of my child, the negligence of the RELEASEES or the negligence of any third party. I further agree that this Release and Waiver of Liability shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Release and Waiver of Liability shall be construed in accordance with the laws of the State of Iowa. 
	I understand that photographs may be taken during the project and may be used in the future to chronicle and publicize the project.  
By checking the Electronic Signature on this Release and Waiver of Liability, I state that I have read and understand the conditions set forth in this Release and that I agree to all conditions set forth herein, and that I sign this voluntarily. 

If participant is 18 or older as of September 16, 2017:
Electronic Signature of participant  Printed name of participant        Date      

If participant is under 18 as of September 16, 2017: Participant’s date of birth:      
I/we       (name(s) of parent/legal guardian) authorize       (name of under-18 participant) to be accompanied on the trip by       (name of authorized adult companion). I,       (authorized adult companion) accept the responsibility for the child’s safety.
Electronic Signature(s) of parent/legal guardian
  Printed name(s) of parent/legal guardian       Date       
Electronic Signature(s) of authorized adult companion guardian 
 Printed name(s) of parent/legal guardian        Date      

IARVCP Medical History Questionnaire
All Information is Confidential 

We would like to have this questionnaire on file in case of a medical emergency. 
Filling out this form could provide us with important information if you are injured. 

Name:       Age:       Date of Birth:      

Gender:    M       F 

Guardian Name and Phone # (if under 18 years old):        

Physician Name and Phone #:      

Emergency Contact Name and Phone Numbers:        

Day            Evening             Cell       

Are you allergic to any medication (aspirin, penicillin, etc.)  Yes    No?  List:      
 
Do you take any medication?   Yes      No    List:      

Have you ever been told by a doctor that you have epilepsy?   Yes      No    
When:      

Have you had recent surgical operations, accidents or injuries?   Yes      No 
When/What      

Have you been “knocked out” unconscious, had a concussion or head injury?  Yes    No    
When/what:      

Are you pregnant?  Yes      No     

Do you wear glasses?  Yes      No     contact lenses?  Yes      No     

Date of last tetanus immunization:      

Please check any of the following medical conditions you have had within the last 5 years: 
	 Hay fever or allergies (especially to bees, ants, etc.)      Heart disease     
   High Blood Pressure      Asthma      Diabetes      Seizures     Fainting Spells 

Do you have any medical training:   
	 Doctor       Nurse       EMT       First Responder       CPR      First Aid      
Other:      

Is there anything else about your health we need to know in case of an emergency? 
     

Electronic Signature:     Printed Name:         Date: