Conservation and Wildlife Management Division

“Preserving Australia’s Heritage”

Queensland Indoor Range

266 Brisbane Street, WestIpswich, Qld 4305

Phone: (07) 38084881

Email:

Field Activity Participant’s Release Waiver and Activity Registration Form

I am aware that participating in any SSAA Conservation and Wildlife Management Field Activity is a potentially dangerous undertaking and that I participate in any activity at my own risk.

I acknowledge that the activity organisers (which term includes all persons involved in the execution of the activity, the SSAA C&WM branch, its executive, committee, the activity coordinator, members, servants or agents) cannot control a range of matters in remote wilderness areas or anywhere else, that may create or vary risks to my health and safety.

Such things include the weather, altered topography and track conditions, personal attributes such as my fitness, level of expertise and my approach to challenges presented.

I am also aware that any person participating in any field activity is only allowed to do so on the distinct understanding that they do so at their own risk.

My signature below acknowledges that of my own free will and desire I have contracted with the organizers to participate in the field activity and that I have read and understood the warning, and release from liability and waiver stated above, and agree to be bound by it as a condition of participation.

Name of Activity:
Activity Area or Name of Property:
Dates of Activity: / to
Participants Name:
SSAA Membership No: / Expiry Date:
Address: / P/code:
Phone: (H) / (Mob)
Date of Birth:
Next of Kin Name:
Relationship to Participant:
Next of Kin Contact details:

______

Do you have any allergies? If so, what please describe them
Do you suffer from any medical conditions? (diabetes, heart condition, high blood pressure, back/neck injury etc) If so, please list them.
______
______
______
Are you on any regular medications? If so, please list them.
Have you driven a vehicle to project? / Yes / No
Make and Model:
Registration Number:
Km’s to and from location:
Have you completed a recognised First Aid Course? / Yes / No
If so, when and who with:

Do you hold a Firearms Licence? If so, please provide the following details.

Shooters Licence Number: / State:
Licence Codes: / Date of Expiry:

I declare that the above details are true and correct and that I am a financial member of the Sporting Shooters Association of Australia and the SSAA (Qld) Inc Conservation & Wildlife ManagementDivision

Signature / Printed Name / Date

SSAA C&WM QLD Division Activity Release and Registration Form, Version 1, Released 21 June 2010