GOOD SPORTS~Consent Form~
NAME

AGE

SEX

DATE

M/F
DATE OF BIRTH///

TELEPHONE NUMBER/

ADDRESSEMERGENCY CONTACT NAME

EMERGENCY CONTACT NUMBER≪Health Questionnaire≫⚫ Are you seeing a doctor now?

Yes/NoIf Yes, please give reason ________________________________________⚫ Are you taking medication?

Yes/NoIf Yes, name of medication _______________________________________⚫ Did you have alcohol in the last 6 hours?

Yes/No(Please note that you will be unable to participate if alcohol is suspected)⚫ Do you have any health problems we need to know for safety reasons?
□ heart problems□ high blood pressure□ pregnancy (including possibility)□ asthma□ bone fracture or dislocation□ allergy□ physically or mentally challenged□ Other ________________________________________________________________≪Private Information Policy≫
・GOOD SPORTS uses your personal information only if you have an accident.
・GOOD SPORTS does not give your personal information to others.
・GOOD SPORTS deletes this consent form immediately when your tour finishes.
・GOOD SPORTS may use photos and videos of this tour for company advertisement.

≪Acknowledgement≫
1. I understand and am aware of the following:⚫

River Rafting / Ducky (rubber kayaking) / Canoeing / Canyoning involve many risks, dangers, and hazards
including, but not limited to: accidents which occur during transportation or travel to and from the river; theoverturning or upsetting of rafts or boats; sudden violent and unexpected movement of the boat or raft;
entrapment by trees, logs, rocks or equipment; hypothermia due to exposure to very cold water and/orweather conditions; falling from the boat or raft into long sections of continuous rapids; impact or collision
with rocks, trees, logs, deadfall, other vessels, and other boating equipment; encounters with domestic orwild animals; high winds; equipment failure; variation in the water conditions, surfaces and currents; andaccidents with other boaters and rafters; falling, tripping or sliding on trails.

⚫

Trekking / Mountain Biking / Mountain Climbing involve many risks, dangers and hazards, including but notlimited to: steep slopes in their natural state that may contain many obstacles and hazards; terrain that
may not have been travelled on or climbed before and is not regularly patrolled or inspected; becoming
lost or separated from the guide or party; rock slides; rapid and extreme change in weather conditions;
inattentiveness of other participants.

⚫

Communication in the backcountry terrain is difficult and, in the event of an accident, rescue and medical
treatment may not be available.

⚫

Due to adverse conditions beyond their control, operators and staff may be unable to safeguard or protect
me from the risks, dangers and hazards of these activities.

2. I agree with the medical treatment, transfer to medical facility and emergency treatment provided by the tour
guides and will assume all medical costs.
3. I will abide by the company insurance policy for any compensation resulting in any physical injury or
damage, and will not hold the company, tour guides, or any other participants further liable.
4. I will follow the tour guide’s instruction and obey the safety guidelines of GOOD SPORTS.
I freely accept and fully assume all risks, dangers and hazards associated with the activities and the possibility of
personal injury, death, property damage or loss resulting therefrom.
I have had sufficient opportunity to read this entire document. I have carefully read, understand and accept theterms and conditions stated herein and acknowledge that this agreement shall be effective and binding uponmyself, my heirs, assigns, personal representative, estate and for all members of my family, including minor
children.

Signature of ParticipantDateSignature of Guardian

Date(Required if participant is under 18 years of age)

GOOD SPORTS Hokkaido Ground Service, Ltd.
Chuo ku, Kita 10 Jo, Nishi 16 Chome 28 Takushoku Building 2F, Sapporo, Japan 060-0010