I, the undersigned, for and on behalf of myself and any minor child(ren) who may accompany me, do hereby release and hold harmless the Mackinaw Canoe Club, its officers, directors, members, and the trip leaders from any and all actions, claims, costs, personal injury, death and medical expenses which may result from my participation in the above referenced activity. This release shall be effective as to my heirs, assigns, executors, and administrators. I acknowledge that there are natural hazards attendant to boating, that the condition of waterways vary with the season and flow and that canoeing and kayaking are potentially hazardous or life threatening activities. I certify that the watercraft that I am using is seaworthy and that both it and my paddling skills are adequate for this instant trip. I further promise to bind my heirs, my administrators, executors, and myself and assigns to repay to the above named releasees, their insurers, successors and assigns any sum of money that they may hereafter be compelled to pay in consequence of my (our) participation in this event.
I HAVE READ THIS DOCUMENT AND UNDERSTAND THE CONTENTS HEREOF.

Name #                          Address                    Emergency Name & Phone # 1.   _________________        _____________________________        ____________________________ 2.   _________________        _____________________________        ____________________________ 3.   _________________        _____________________________        ____________________________ 4.   _________________        _____________________________        ____________________________ 5.   _________________        _____________________________        ____________________________ 6.   _________________        _____________________________        ____________________________ 7.   _________________        _____________________________        ____________________________ 8.   _________________        _____________________________        ____________________________ 9.   _________________        _____________________________        ____________________________ 10.   _________________        _____________________________        ____________________________ 11.   _________________        _____________________________        ____________________________ 12.   _________________        _____________________________        ____________________________ 13.   _________________        _____________________________        ____________________________ 14.   _________________        _____________________________        ____________________________ 15.   _________________        _____________________________        ____________________________ 16.   _________________        _____________________________        ____________________________

Trip Leader: You can use this form to list each trip you take this season and to keep attendance on those trips. Please forward all sheets to Marilyn Black, MCC Secretary/Treasurer, RR 2 Box 5, Clinton, IL 61727, for the annual trip summary report.

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