Guest Form

General Information:
Full Name:(Required)
Name of VIP You Are Attending With:(Required)

In Case Of Emergency, Notify The Person Below:
Alternate Contact Name:(Required)

Dose of the Coast Event Risk Advisory to Health-Care Providers, Participants, and Family

Coastal Experience:
Participation in any Dose of the Coast event or in any coastal, water-based, activity can be potentially physically, mentally, and emotionally demanding. Each coastal adventure offers a unique experience that is not risk-free. Knowledgeable staff will instruct all participants in safety measures to be followed. Be prepared to listen to and carefully follow these safety measures and to accept responsibility for the health and safety of yourself and others.
Coastal Experience Requirements:
Each person must be able to lift a minimum of 20lbs to participate in the fishing portion of the event. Although it will be avoided as much as possible, there will be potentially rough, wet, and muddy conditions. These conditions can potentially lead to tripping, slipping, and falling. All participants must wear closed-toed shoes while on the boats. Long sleeve shirts and long pants are recommended to prevent scrapes on arms and legs, and sunburn. Climatic condition averages can range from 47-62 in winter (December-January), 65 to 70 degrees in the spring (February-April), 60-100+ in summer (May-August), and 53-87 degrees in fall (September-November). Each person should be prepared for hot sunny conditions or cooler windy conditions, depending on the season, and always be prepared for potentially rainy conditions. Shade will be provided as often as possible and events will be planned around good-weather conditions, but often, weather can change unexpectedly. Water will be provided throughout the entire event, and hydration will be encouraged.
Be prepared:
While participating in a Dose of the Coast event, provided life jackets must be worn at all times when on the water. Crew members travel together at all times. Emergency communications via radio and cell phone will be provided by boat captains and Dose of the Coast staff. Radio communication and/or emergency evacuation can be hampered by weather, terrain, distance, time of day, equipment malfunction, and other factors, and are not a substitute for taking appropriate precautions and having adequate first-aid knowledge and equipment.
Dose of the Coast activities will take place outdoors. Whenever possible, events will be planned with an air conditioned area close by.
Sun, rain, lightning, sea spray, sea sickness, rough waters, slippery and wet decks all may be encountered while at an event.
Many events will take place on a boat, which will require participants to step on and off of.
Dress for the weather. A hat, sunglasses, rain jacket, long sleeve shirt and long pants are suggested.
Closed-toed shoes are mandatory.
An extra set of clothes to change into is suggested.
Illegal drugs or alcohol is not allowed. Intoxicated persons will not be allowed to participate.
All event activities are voluntary and can be terminated at any time by the participant.
Different cancer treatments effect the immune system differently. This is one of the reasons we ask Dose of the Coast participants to get medical clearance from their doctor. Please be sure to address all of your concerns with your doctor or Dose of the Coast staff.
Meals may be provided, based on the event planned.
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Informed Consent, Release Agreement, and Authorization

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I understand that participation in Dose of the Coast activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from the venue or activity coordinators. I also understand that participation in these activities is entirely voluntary and requires participants to follow instructions and abide by all applicable rules and the standards of conduct.
In case of an emergency involving me or my family member, I understand that efforts will be made to contact the individual listed as the emergency contact person by the medical provider and/or event leader. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the event leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my family member. Medical providers are authorized to disclose protected health information to the person in charge, on-site medical staff, event management, and/ or any physician or health-care provider involved in providing medical care to the participant. Protected Health Information/ Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant or participant’s parents and/or guardian, and/or determination of the participant’s ability to continue in the program activities.
I have carefully considered the risk involved and hereby give my informed consent to participate (or my family member to participate) in all activities offered in the program.I further authorize the sharing of the information on this form with any Dose of the Coast volunteers or professionals who need to know of medical conditions that may require special consideration in conducting event activities.
With appreciation of the dangers and risks associated with programs and activities, on my own behalf and/or on behalf of my child, I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against Dose of the Coast, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.
I also hereby assign and grant to the local council and Dose of the Coast, as well as their authorized representatives, the right and permission to use and publish the photographs/film/vide tapes/electronic representations and/or sound recordings made of me or my family member at all Dose of the Coast activities, and I hereby release Dose of the Coast, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I further authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film videotapes/electronic representations and/or sound recordings without limitation at the discretion of Dose of the Coast, and I specifically waive any right to any compensation I may have for any of the foregoing.
NOTE: Due to the nature of programs and activities, Dose of the Coast and local councils cannot continually monitor compliance of program participants or any limitations imposed upon them by caregivers or medical providers. However, so that leaders can be as familiar as possible with any limitations, list any restrictions imposed on a participant in connection with programs or activities below.
List participant restrictions, if any:
I understand that, if any information I/we have provided is found to be inaccurate, it may limit and/or eliminate the opportunity for participation in any event or activity. If I am participating in a fishing, canoeing, kayaking, sailing event, meals, or any other associated activty, I have also read and understand the supplemental risk advisories, and understand that I will not be allowed to participate in applicable programs if those requirements are not met. The participant has permission to engage in all activities described, except as specifically noted by myself or the health-care provider. If the participant is under the age of 18, a parent or guardian’s signature is required.
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