Indigenous SUP Program Lakes Entrance

Thank you for registering to come Stand Up Paddle Boarding with Surfing Victoria.

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* 1. Name of Participant:

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* 2. Year of Birth:

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* 3. What is your gender?

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* 4. Post Code:

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* 5. Are you eligible for a healthcare card?

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* 6. Email Address:

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* 7. Phone Number

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* 8. Where were you born?

Medical Information

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* 9. Does participant have any existing medical conditions:

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* 10. Does participant have any allergies:

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* 11. Current Medication:

Emergency Contact

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* 12. Contact Name:

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* 13. Relationship:

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* 14. Contact Mobile:

Participant Agreement
In consideration of the Organiser accepting my application to participate in Coasting: Stand Up Paddleboarding ("Program"), I acknowledge and agree that:

In this agreement:
"Claim" means and includes any action, suit, proceeding, claim, demand, cost or expense however arising including but not limited to negligence.

"Organiser" means and includes SA, SV, other SA affiliated state surfing associations and, where the context so permits, their respective directors, officers, members, servants, agents or contractors.

"SA" means Surfing Australia Incorporated.

"SV" means Surfing Victoria Incorporated.

2. If my application is accepted I will participate in the Program. I acknowledge my application will be deemed to be accepted upon my participation in the Program and I acknowledge that I will be bound by and agree to comply with the program rules, regulations and policies of the Organiser as they relate to the Program.

3. Warning: Surfing Activities can be inherently dangerous. I acknowledge that I am exposed to certain risks during my participation in the Program including but not limited to physical hazards, unpredictable and sometimes dangerous surf and weather conditions and actions of other participants.

I acknowledge that accidents can and often do happen which may result in me being injured or even killed, or my property being damaged. I have voluntarily read and understood this warning and accept and assume the inherent risks in participating in the Program.

4. Release and Indemnity: In consideration of the Organiser accepting my application for participation I, to the extent permitted by law:

(a) release and will release the Organiser from all Claims that I may have or may have had but for this release arising from or in connection with participation in the Program; and

(b) indemnify and will keep indemnified the Organiser in respect to any Claim by any person arising as a result of or in connection with my participation in the program.

5. Fitness to Participation: I declare that I am medically and physically fit and able to participate in the Program. I will immediately notify the Organiser in writing of any change to my medical condition, fitness or ability to participate. I understand and accept that the Organiser will continue to rely upon this declaration as evidence of my fitness and ability to participate. I understand and accept that the Program is designed for people who have a basic surf skills being beyond the beginner level of surfing, are able to swim 200 metres and are able to catch wave, and I meet this criteria.

6. Medical Treatment: I consent to receiving any medical treatment that the Organiser reasonably considers necessary or desirable for me during my participation in the Program. I also agree to reimburse the relevant Organiser for any costs or expenses incurred in the providing me with medical treatment.

7. Right to Use Image: I acknowledge and consent to photographs and electronic images being taken of me during my participation in the Program. I acknowledge and agree that such photographs and electronic images are owned by the Organiser may use the photographs for promotional or other purposes without my further consent being necessary. Further, I consent to the Organiser using my name, image, likeness and also my performance in the program, at any time, by any form of media, to promote the Program.

I acknowledge and agree that, photographs, sound recordings or audio-visual recordings in which I appear will be provided to the Victoria Health Promotion Foundation (ABN: 20 734 406 352) (VicHealth) who may use those items internally or externally to promote i

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* 15. By checking this box, I acknowledge that I have read, understood and agree to the terms stated including the warning, release and indemnity,

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* 16. Date

Date

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