Member Form

Personal information

AddressMailing address *

Health Sheet

Has a health care professional ever told you that you have or may have a heart problem? *

YesNo

Has a health care professional ever told you that your blood pressure is too high or irregular? *

YesNo

Do you experience chest or heart pain during exercise and/or at rest? *

YesNo

Do you experience dizziness, weakness or loss of consciousness during exercise and/or at rest? *

YesNo

Do you suffer from joint or bone problems that could be aggravated by intensive physical activities, harsh weather conditions or difficult transportation conditions? *

YesNo

Do you have difficulty adapting to heat and/or cold? *

YesNo

Do you wear contact lenses, glasses or other prostheses? *

YesNo

Do you have any visual problems such as difficulty judging distances, heights or colors, very high sensitivity to light or other? *

YesNo

Do you have enough hearing problems that you have difficulty communicating with people near or far? *

YesNo

Do you have any dermatological (skin) problems that appear or are aggravated by the sun, heat or cold? *

YesNo

Do you have any phobias (fear of heights, water, darkness, confined spaces or other)? *

YesNo

Are you suffering or have you ever suffered :
Allergies (cold, nuts, food, medication or other) Emotional, psychological or psychiatric problemsDiabetes or hypoglycemiaEpilepsyHemophiliaOther diseases, chronic infections, hepatitis or health disorders

Have you had any previous or recent injuries or operations (tendonitis, strains, etc.)? *

YesNo

Do you have a disability that may restrict physical activities? *

YesNo

Do you take medication on a daily basis? *

YesNo

If you answered "yes" to any of the above questions, please specify here. 

Are you pregnant? *

YesNo

Do you have any dietary restrictions (vegetarian, food intolerance, etc.)? *

YesNo

If you answered "yes" to any of the above questions, please specify here. 

I accept the additional risks that could result in a possible worsening of my health condition. *I agree to inform the leaders if there are any changes in my health/physical or psychological condition. *

Certificates and authorizationsA - Risks inherent to the activityI acknowledge that the risks of the activities in which I will participate are in particular but not limited:

A fall or other movement (sprain, strain, fracture, etc.);
An inclined and uneven terrain, with improved or unimproved paths, with little or no apparent obstructions, where a person can get to or into a dangerous situation;
Risks inherent to the weather (thunderstorms, snowstorms, etc.) and to the environment (rockslides or falling rocks, trees, ice, avalanches or other materials;
Wild or domestic animals, or poisonous or irritating plants;
Behaviour, even negligence, on the part of other users;
Unsafe permanent anchors that do not protect in case of a fall;
Failure of personal protective equipment
Frostbite or hypothermia, burns or heat disorders

B - Recognition and acceptance of risksI accept that the outing I am undertaking involves risks that may cause injury or death. These risks are identified in, but not limited to, the paragraph above. I accept the nature of these risks as an integral part of the outing, as well as the consequences that may result from them. I acknowledge that the activity is conducted in rugged, remote and difficult to access terrain. In case of need, communication will be difficult, rescue will be long and arduous, and medical care cannot be administered in a timely manner. I understand that teachers may exclude anyone who may pose a risk to themselves or others.

C - Release of responsibility for the materialI, the undersigned, hereby waive all claims, as well as all lawsuits for damages for any damage to property and materials belonging to me (normal wear and tear, loss, breakage, theft, vandalism).

D - Participant's commitment

I affirm that I have the health, physical fitness and mental attitude required for such an outing.
I agree to conduct myself at all times in a responsible and safe manner so as to eliminate or reduce the consequences of these risks to myself and others.
I agree to respect at all times the instructions and directives given by the persons in charge.
I commit myself to ask clearly what to do when faced with a difficulty that is unknown to me, and to indicate my willingness not to perform a maneuver that seems too difficult.
I agree not to go beyond my abilities and to notify the person in charge of the activity of any discomfort, pain or symptoms experienced during the activity.
I declare that I am not under the influence of alcohol or any other drug and I formally commit myself not to use them during the program.
I affirm that I have read and understood this document and am undertaking the program with full knowledge of the facts.

E - Confirmation of information and acceptance of risksI certify that the information on this form is accurate to the best of my knowledge. I certify that I have not deliberately omitted any information about my health status, whether relevant or not. I am aware that the information contained in this form is confidential and is intended for the purpose of planning and supervising the safety of the activities in which I will be participating, and that it will enable the organizers to draw up a profile of the participants. I am aware that the activities of the program take place in semi-natural or natural environments that may be rugged and, consequently, are further away from medical services. This could result in long delays in the event of an emergency requiring evacuation, and consequently, a possible aggravation of my condition or injury. Having been informed of these risks and having had the opportunity to discuss them with those in charge, I acknowledge that I have been informed of the risks inherent to the activities and that I am able to undertake the outing in full knowledge of the facts and accepting the risks that this activity may entail. I also agree to play an active role in the management of these risks by adopting a preventive attitude towards myself and other people around me. The leader reserves the right to exclude any person he/she deems to be a risk to him/her or to the rest of the group.

F - Alcohol and Drug PolicyAlcohol consumption is permitted after Chèvres events for one drink only; the blood alcohol limit of 80 mg/100 ml of blood (0.08) must be respected at all times. More than one drink may be permitted at events where a couch is involved, as long as the blood alcohol limit (0.08) is met. Drug use is not permitted at any of Les Chèvres events, and impaired persons may be refused entry to the events. It is your responsibility not to be in possession of or under the influence of any illegal drugs or substances. Failure to comply with these rules may result in a risk to your safety and the safety of others. Les Chèvres de Montagne will not be held responsible for any incident or accident resulting from the use of alcohol, drugs, illicit substances or medication. I have read the policy.

Date signed *

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Health sheet

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