APPLICATION FORM
MEDICAL AND PERSONAL INFORMATION

5109 - 17A Avenue NW
Edmonton, AB, Canada T6L 1K5
(780) 461 - 5040 fax / voice

email:

Last Updated Saturday, April 26, 2014

WARNING: The prices, dates, locations, policies and information in this document are subject to change without notice.

The application forms contained in this document are also available as an Adobe Acrobat .pdf file for downloading. We highly recommend you view and print that version for the best formatting for ALL makes and models of computer and printer. (Windows and Macintosh friendly.) If you have problems downloading or printing the document, please email us and we will try to rectify the problem and send you a paper copy via regular mail. Please review the complete cancellation policies and procedures. We recommend purchasing cancellation insurance through a travel agent in case you are unable to attend due to medical or other emergency.


RESCUE DYNAMICS

5109 - 17 A Avenue NW, Edmonton, Alberta, Canada T6L 1K5
phone / fax (780) 461 - 5040
email:
website: http://www.RescueDynamics.ca

APPLICATION FORM, MEDICAL AND PERSONAL INFORMATION

Fill out the following as completely as possible.

NAME _____________________________________________________________________________

ADDRESS: _________________________________________________________________________

CITY: ____________________________________ PROVINCE: ______________________________

POSTAL CODE: _________________________

PHONE - HOME _________________________ WORK ____________________________________

FAX ____________________________________ CELL ____________________________________
Will you have your cell phone with you during the course in case of emergency? YES / NO

EMAIL: ___________________________________________________________________________
Do you wish to receive email correspondence regarding this course or other courses? YES / NO

COURSE YOU WISH TO ATTEND: ___________________________________________________

COURSE DATE: ___________________________________________________________________

EMERGENCY CONTACT - NAME: ___________________________________________________

PHONE - HOME _________________________ WORK ___________________________________

AGE: (_) <19 (specify:____) (_)19 - 25 (_) 25 - 35 (_) 35 - 45 (_) 45 - 55 (_) 55 - 65 (_) 65 - 75 (_) >75

(_) I have enclosed full course payment or required deposit. Amount enclosed ____________________

(_) I have read, understood, and agree to, the Booking and Cancellation Policies and Procedures.

Applicant's Signature ____________________________________ Date _______________________

I require the following equipment (provided at no additional cost):

large day pack yes no
helmet yes no
harness yes no - waist size in inches _____________
carabiners (2 locking) yes no
prusik slings yes no
rescue pulley yes no - for activities with glacier travel
crampons yes no - snow or ice courses only
ice axe yes no - snow, ice or glacier courses only
technical ice tools (2) yes no - winter ice climbing courses only
avalanche beacon yes no - avalanche & ski touring courses only
lightweight shove yes no - avalanche & ski touring courses only
avalanche probe yes no - avalanche & ski touring courses only

MEDICAL Fill out the following as completely as possible.

Describe any history of past or current medical problems or conditions which you may have. In particular. describe any special problems you may have which could affect your hiking, climbing or skiing ability. (Use a separate sheet of paper if necessary):

 

 

Are you currently taking any medications? _ NO / _ YES (please list.)

Are you sensitive, or allergic to any foods, medications or other substances? _ NO / _ YES (please list.)

 

 


PREVIOUS BACKGROUND : Describe the skill areas in which you are the strongest and the skill areas in which you are the weakest. This allows the activities to be tailored to your abilities. Do not be afraid to state that you have no previous experience. For courses with prerequisites, list qualifying courses taken and date.

 


ASSOCIATION OF CANADIAN MOUNTAIN GUIDES

PARTICIPANT AGREEMENT

RELEASE OF LIABILITY, WAIVER OF CLAIMS AND ASSUMPTION OF RISKS

WARNING: BY SIGNING THIS DOCUMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS

PLEASE READ CAREFULLY

In consideration of the Guide (as defined below) accepting my application for and permitting me to participate in a Guided Mountaineering Trip (as defined below) on lands owned by or under the control of the Provinces as defined below or elsewhere, the following waiver of all claims, release from all liability, assumption of all risks, agreement not to sue, and other terms of this agreement (collectively this "Agreement") are entered into by me with and for the benefit of:

(Cyril Shokoples operating as Rescue Dynamics) (collectively, the "Guide")
AND Her Majesty the Queen in Right of the Provinces of British Columbia and Alberta (the "Provinces")
AND British Columbia Assets and Land Corporation (BCALC)
AND The Association of Canadian Mountain Guides (the "ACMG")
AND the Personnel, BCALC's Personnel and the Province's Personnel (all as defined below)

Definition - In this Agreement the term "Guided Mountaineering" and "Guided Mountaineering Trip" shall include all activities in any way related to mountaineering, rock climbing, sport climbing, ice climbing, skiing (including ski-touring, ski mountaineering, snowboarding, and similar activities), glacier travel, trekking, hiking, all schooling and instruction sessions, loading and unloading of vehicles and camping or overnight stays in the outdoors.

I WAIVE ANY AND ALL CLAIMS that I have or may in the future have against and RELEASE FROM ALL LIABILITY AND AGREE NOT TO SUE the Guide and his/her/its shareholders, directors, officers, employees, agents, assistant guides, instructors, independent contractors, subcontractors, and representatives (collectively, the "Personnel"), the ACMG, BCALC, BCALC's servants, employees, and agents (collectively "BCALC's Personnel") either or both the Provinces and each of the Provinces' respective servants, employees, and agents (collectively the "Provinces' Personnel" and, together with the Guide, the ACMG, BCALC, BCALC's Personnel, and the Personnel, collectively called the "Releasees") for any loss, property damage, expenses, or personal injury (including death) that I may suffer, or that my next of kin may suffer as a result of my participation in a Guided Mountaineering Trip DUE TO ANY CAUSE WHATSOEVER ON THE PART OF THE GUIDE, THE PERSONNEL OR THE ACMG, INCLUDING:

(a) negligence (the meaning of which includes failure to use such care as a reasonably prudent and careful person would use under similar circumstances and failure to meet standards of care in the mountain guiding industry in Canada for the safety of participants on a Guided Mountaineering Trip);
(b) breach of any other duty imposed by law, including any duty imposed by occupiers liability or other legislation;
(c) breach of any contract; and
(d) mistakes or errors in judgment of any kind on the part of the Releasees.

I AGREE TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any loss, property damage and personal injury (including death) to any third party resulting from my participation in a Guided Mountaineering Trip.

I AM AWARE THAT GUIDED MOUNTAINEERING AND PARTICIPATION IN A GUIDED MOUNTAINEERING TRIP HAVE CERTAIN DANGERS AND INHERENT AND OTHER RISKS, SOME OF WHICH INCLUDE:

AVALANCHES, ROCK FALL, ICE FALL OR CORNICE FALL - which frequently occur in terrain used for Guided Mountaineering and may be caused by natural forces including slope incline, snowpack, ice, rock or glacier instability, or by changing weather conditions, or by other climbers or skiers or by a helicopter or the failure for any reason of the Releasees to predict whether the terrain is safe for Guided Mountaineering or where or when an avalanche, ice fall, rock fall or cornice fall may or may not occur;

MOUNTAINOUS AND STEEP TERRAIN - where a fall, whether roped or unroped, may cause injury or death. In addition, the areas used for Guided Mountaineering have steep or vertical slopes, overhangs and cornices which in their natural state have inherently dangerous obstacles and hazards. Some of these obstacles and hazards include glacier crevasses, rocks and boulders, tree wells, tree stumps, forest deadfall, still and moving water, holes and depressions, and varying and difficult snow and climbing conditions. These mountainous areas have dangerous man-made obstacles and hazards which may include roads, steep trails, fences, bridges and other structures. The areas used for Guided Mountaineering may have not been travelled previously and are not regularly patrolled or examined. I acknowledge I may become lost or separated from the Personnel or my companions because of weather, forested areas and wild and rugged terrain;

WEATHER - weather conditions can be extreme and can change rapidly without warning;

AEROPLANE OR HELICOPTER OR OTHER MEANS OF MECHANIZED TRAVEL - additional risks are posed by mechanized travel in mountainous areas due to mechanical failure, operational error and changeable weather conditions;

WILD AND/OR POISONOUS PLANTS, ANIMALS, AND INSECTS - which are unpredictable in nature and may affect or attack mountain travellers;

CONDUCT OF RELEASEES - the conduct, including NEGLIGENCE, of the Releasees;

ILLNESS - which may be caused, among other things, by altitude, untreated water, plants and animals, or the difficulty of maintaining hygiene on Guided Mountaineering Trips;

PROXIMITY OF MEDICAL CARE - which may not be readily available or effective in a Guided Mountaineering Trip;

CHOICE AND USE OF EQUIPMENT - mountaineering equipment may become faulty or fail or become inappropriate and may not be replaceable or repairable in the course of a Guided Mountaineering Trip; and

USE OF NON-RELEASABLE BINDINGS - "telemark" skiers and snowboarders and other participants who choose to use bindings that do not or may not automatically release in the case of a fall or other emergencies are at greater risk of injury or death in an accident or avalanche.

I accept all the dangers and risks of Guided Mountaineering including without limitation the risks described above and the possibility of personal injury including death, property damage, loss or expenses resulting therefrom. I acknowledge that the enjoyment and excitement of Guided Mountaineering is derived in part from climbing or skiing on steep slopes in mountainous terrain and that the inherent risks of Guided Mountaineering contribute to such enjoyment and excitement.

I agree that, although the Releasees may take precautions to reduce the risks and increase the safety of a Guided Mountaineering Trip, it is not possible for the Releasees to make Guided Mountaineering completely safe or free from risk. I willingly accept all the risks and dangers of Guided Mountaineering and I willingly agree to the terms of this Agreement even if the Releasees are found in law to be negligent or in breach of a duty of care or any other obligation to me in the conduct of any Guided Mountaineering Trip.

In entering into this Agreement I am not relying on any oral, visual or written representations or statements made by the Releasees with respect to the safety of Guided Mountaineering other than what is set forth in this Agreement.

I agree that this waiver and the agreements it contains will be governed in all respects by and interpreted exclusively in accordance with the laws of the Province of British Columbia and I irrevocably attorn solely to the jurisdiction of the courts of the Province of British Columbia.

I agree that if any portion of this Agreement is found to be void or unenforceable, the remaining portions of this agreement shall remain in full force and effect.

I confirm that I am of the full age of nineteen years and that I have read and understood this Agreement prior to signing it and agree that this Agreement will be binding upon my heirs, next of kin, executors, administrators, assigns and representatives in the event of my mental incapacity or death.

Signed this __________ day of __________________, 20___ , in the presence of:

________________________________ ________________________________
Signature of Witness Signature of Participant
________________________________ ________________________________
Print Name of Witness Print name of Participant
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
Print Address of Witness Print Address of Participant


Version: May 30, 2001


RESCUE DYNAMICS - BASIC SUMMER CLIMBING EQUIPMENT CHECKLIST
prepared by CYRIL SHOKOPLES © 1986, 2000

ESSENTIAL ITEMS
( ) Bag Lunch for each day of the course ( ) Leather gloves
( ) Rain gear (pants, jacket) ( ) Toilet paper (small personal supply)
( ) Boots or rock climbing shoes, as appropriate ( ) Moleskin for Blisters
( ) Sunglasses or Glacier Goggles ( ) Water bottle / thermos
( ) Lipsalve / Sunblock (SPF 15 or better) ( ) Sunscreen cream (SPF 15 or better)
( ) Toque / balaclava ( ) Warm jacket or sweaters
( ) Sun Hat ( ) Day Pack
( ) Gaiters - for courses involving snow or ice only ( )
All of the above to be packed in your Day pack. Your day pack should still have room for some group climbing equipment.

CLOTHING
( ) Pants or knickers ( ) Long sleeve shirts
( ) T-shirts, long johns ( ) Wind pants or warm-ups
( ) Socks & underwear ( ) Gloves or Mittens
( ) Anorak / outer jacket ( ) Handkerchief
( ) Snowseal / boot waterproofing ( ) Spare laces
( ) Extra change of clothing left in the car for your return

CAMPING EQUIPMENT (for those who will be camping)
( ) Sleeping Bag, pillow ( ) Foamie / ensolite / thermarest
( ) Tent, Fly & poles ( ) Ground sheet
( ) Food ( ) can opener
( ) Cup & bowl ( ) Eating utensils
( ) Pots / pans & holder ( ) Stove & Gas
( ) Matches &/ Lighter ( ) Candles
( ) Flashlight / headlamp ( ) Spare batteries & bulb
( ) Pocket knife ( ) Garbage bags
( ) Comfortable shoes ( ) Saw or axe
( ) Fire starter ( ) Sponge or J-cloth

PERSONAL ITEMS
( ) Money ( ) Personal identification
( ) Insect repellent ( ) Personal medications
( ) Personal First Aid Kit ( ) Toothbrush, paste
( ) Soap, towel, brush ( ) Shaving kit, comb
( ) Swimsuit / shorts ( ) Camera & Film
( ) Reading material ( ) Writing material

CLIMBING EQUIPMENT (Optional - all technical gear except rock shoes & mountaineering boots provided)
( ) Helmet ( ) Climbing rope
( ) Harness ( ) Rescue pulleys
( ) Carabiners ( ) Pitons & hammer
( ) Prusik slings (two 7mm X 5m) ( ) Chocks, nuts, cams, etc.
( ) Slings for anchors & runners ( ) Rappel device
( ) Belay device ( ) Bolt hangers
For snow & ice and alpine climbs or courses add the following
( ) Ice Axe ( ) Crampons
( ) Ice screws ( ) Snow anchors


RESCUE DYNAMICS - BASIC WINTER CLIMBING EQUIPMENT CHECKLIST
prepared by CYRIL SHOKOPLES © 1993, 2000

ESSENTIAL ITEMS
( ) Sleeping Bag for Hostel ( ) Pillow for Hostel
( ) Bag Lunch for each day of the course ( ) Leather gloves
( ) Rain gear (pants, jacket) ( ) Toilet paper (small personal supply)
( ) Plastic Mountaineering Boots or Ski Boots ( ) Moleskin for Blisters
( ) Sunglasses or Glacier Goggles ( ) Water bottle / thermos
( ) Lipsalve / Sunblock (SPF 15 or better) ( ) Sunscreen cream (SPF 15 or better)
( ) Toque / balaclava & Scarf or neck tube ( ) Warm jacket or sweaters
( ) Sun Hat ( ) LARGE day pack
( ) Gaiters ( ) Garbage bag
( ) Ski gloves ( ) Spare warm mittens
( ) Wool Socks (multiple pairs) ( ) Nylon or waterproof overmitts
All of the above to be packed in your Day pack. Your day pack should still have room for some group climbing equipment.

CLOTHING for COLD Weather - Dress In Layers
( ) Pile Pants or knickers ( ) Long sleeve shirts
( ) T-shirts, long johns ( ) Wind pants or ski warm-up pants
( ) Socks & underwear ( ) Gloves or Mittens
( ) Anorak / outer jacket ( ) Handkerchief
( ) Snowseal / boot waterproofing ( ) Down or pile jacket
( ) Extra change of clothing left in the car for your return

Essential Ski Equipment (for avalanche & Ski Touring courses only)
( ) Metal edged Skis & Bindings ( ) Ski touring boots
( ) Ski poles ( ) Skins for skis
( ) X-C ski wax (green, blue, purple) ( ) Scraper & cork

Optional Personal Equipment (for avalanche & Ski Touring courses only)
( ) X-C ski overboots ( ) Compass (with clinometer is best)
( ) Altimeter ( ) Whistle & Mirror
( ) Matches / Lighter ( ) Candle
( ) Snow shovel (lightweight) ( ) Metal thermos
( ) Avalanche Beacon (i.e. Pieps, Ortovox, etc.) ( ) Camera & Film
( ) Map of area ( ) Writing material
( ) Avalanche probe ( ) Emergency toboggan (instructor)
( ) Spare collapsible ski pole (instructor) ( ) Spare bulb / batteries for headlamp

Optional Repair Kit (for avalanche & Ski Touring courses only)
( ) Spare cable ( ) Spare basket
( ) Spare bale for X-C bindings ( ) Spare binding parts
( ) Spare binding screws, nuts, bolts ( ) Needles & thread or sewing awl
( ) Pliers or vice grips ( ) Screwdriver & bits
( ) Adjustable wrench ( ) Spare ski tip
( ) Nylon cord (20' or 6m) ( ) Hose clamps
( ) Snare wire ( ) Fiberglass tape or duct tape
( ) Epoxy ( ) Bivouac sac (instructor)

CLIMBING EQUIPMENT (Optional - all technical gear except mountaineering boots provided / not required on avalanche courses)
( ) Helmet ( ) Climbing rope
( ) Harness ( ) Rescue pulleys
( ) Carabiners ( ) Prusik slings (two 7mm X 5m)
( ) Slings for anchors & runners ( ) Rappel device
( ) Belay device ( ) Abalakov wire
( ) Ice Axe ( ) Ice hammer
( ) Ice screws / snargs ( ) Crampons



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Rescue Dynamics
5109 - 17A Avenue NW
Edmonton, AB, Canada T6L 1K5
phone (780) 461 - 5040 voice / fax