Kyoei Corporation（Canoe slalom center） Ｐｒｏｇｒａｍ
Participation Pledge and Parental Consent Form
Please fill out one form per person.
If you are participating as a family member (with the same residence and emergency contact information),
the representative (parent/guardian) should write one form together and enter the family's information in
the accompanying person's columns on the reverse side.

To: Kyoei Corporation
I pledge the following items in participating in the program sponsored by Kyoei Co.
・ I hereby certify that I will voluntarily participate in the program sponsored by Kyoei Co.
・ I understand that this program involves potential hazards and that I may encounter injury(including permanent injury or death) myself, and therefore I will follow the instructions of thestaff and actively cooperate with their safety practices.
・ Guides may not be able to provide explanations in foreign languages.
・ I haven’t been drinking ａｌｃｏｈｏｌ, and I am in good health and not pregnant or possibly pregnant. If
I become ill while participating in the program, I will immediately notify the staff that I will nolonger participate in the program.
・I accept that photos and videos taken during this program may be used on the canoe slalom
center website, SNS , printed materials, etc for public relations and advertising purposes.
*Please check the box below if you do not allow the use of photos or videos.

【□ Do not consent to their use.】

Date of Participation(date)/(month)/(year)

Participant Name（signature）

parental consent column
I the above named participant,hereby agree to participate in theprogram and sign my signature.

parent or
guardian'ssignature※If the participant is under the age listed below, a parent or guardian's signature is required(rafting tour: high school students and under / canoeing experience: junior high school
students and under). Other than this, please check the website for details about otherprograms.

Participating Programs☑ check the box□Rafting Tours□Other （□Canoe Experience）

To the back ➡

Representative
First Namedate month year
Date ofName

Last Name//

BirthAge
Phone orAdress

SafetyManagement
QuestionsE-mail address【1】I have had a dislocation within the last 5 years.

Yes / No【2】I have chronic medical conditions such as high blood pressure,heart disease, asthma, epilepsy, etc.
→If 「yes」, please provide details.
（）

Yes / No

【3】Please write any other concerns you have about participating in the program.
（）

Accompanying person (same address and emergency contact)
Participation Pledge

Name

Date of Birth(date/month/year)/////Signature
Parental consent signatures
for eligible applicants.

/////

Safety Management
Questions
Please check if applicable□not applicable□applicable(【1】 ・ 【２】)□not applicable□applicable(【1】 ・ 【２】)□not applicable□applicable(【1】 ・ 【２】)□not applicable□applicable(【1】 ・ 【２】)□not applicable□applicable(【1】 ・ 【２】)Emergency Contact※Please fill in either 【1】your contact in your home country or 【2】 your guarantor in Japan.

【1】 Emergency contact in your home countryName

E-mail address

Relationship to you：
【2】 your guarantor in Japan
Name

Phone
E-mail address

Relationship to you：
※Personal information obtained will be handled strictly in accordance with our personal information
management policy and will not be used for any purpose other than to respond to accidents that occur
during participation in the program.