Public Education Request Form

Personal information collected on this form by the City of Port Coquitlam will only be used for the purposes for which it was collected under the authority of section 26(c) of the Freedom of Information and Protection of Privacy Act (FOIPPA). If you have any questions regarding the collection of this information, please contact the City’s Records and FOIPPA Administrator at 604-927-5250 or clerks@portcoquitlam.ca.

Date of event: *

Time of event:

Event location:

Organization or Service Group:

Type of Public Education requested (eg. fire extinguisher training):

Contact Person: *

Phone *

Alternate Phone

Email *

Number of Attendees *

Age(s) if minors:

Comment/Additional Information:

Liability, Waiver Of Claims & Indemnity Agreement

In consideration of being allowed to participate in the above-referred to activity of the City of Port Coquitlam and the City of Port Coquitlam Fire & Emergency Services Department, I hereby agree as follows:
1. TO WAIVE any and all claims that I have or may in the future have against the City of Port Coquitlam and the City of Port Coquitlam Fire & Emergency Services Department and their officers, employees, agents, volunteers and representatives (all of whom are hereafter collectively referred to as “the Releasees”); related in any way to the activity.

2. TO RELEASE the Releasees from any and all liability for any loss, damage, injury and expense I may suffer or that my next of kin or heirs may suffer as a result of my involvement in the above-referred to activity and my presence at the City of Port Coquitlam Facilities or the scene of any emergency or Fire Department activity due to any cause whatsoever INCLUDING NEGLIGENCE, BREACH OF CONTRACT OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE OCCUPIERS’ LIABILITY ACT, R.S.B.C. 1979, c.303, ON THE PART OF THE RELEASEES;

3. TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any damage to property of, or personal injury to, any third party, resulting from participation on the above-captioned activity or attendance at the scene of the emergency;

4. This Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, assigns and representatives in the event of my death or incapacity.In entering into this Agreement, I am not relying upon any oral or written representations or statements made by Releasees other than what is set forth in this Agreement.

I Acknowledge *

I have read and understood this Agreement and I am aware that by checking this box I am waiving certain legal rights which I, or my heirs, next of kin, executors, administrators, successors or assigns may have against the Releasees. *

Electronic Signature *

Please type your First and Last Name

Date signed: *