Mentorship Student Registration Form

I wish to be involved in mentorship experiences with rural physicians made possible through the Rural Mentorship Program (“the Program”) organized and conducted by Alberta’s Rural Health Professions Action Plan (RhPAP) and in consideration of RhPAP allowing me to attend and participate in the Program:

1. I acknowledge that my attendance and participation in any part of the Program exposes me to risks and dangers, including, without limitation, risks and dangers inherent to the nature of the Program, risks and dangers resulting from human error and negligence on the part of the persons preparing, organizing and leading the Program, risks and dangers that are foreseeable, and also not foreseeable (the "Risks and Dangers").


2. I acknowledge that the Risks and Dangers may cause damage or loss of personal property, personal injury and even death, and I assume and accept the Risks and Dangers.


3. I hereby release and waive any and all claims against RhPAP in respect of any damage or loss of personal property, personal injury and death or resulting from the Risks and Dangers, whether in contract, tort, equity or however caused, which I may have or may acquire as a result of my attendance at or participation in the Program, including, without limitation, damage, loss, injury and death caused by negligence on the part of RhPAP.


4. I agree to indemnify and save RhPAP harmless from and against any and all claims, costs and expenses RhPAP may incur or be found liable for, as a result of my attendance or participation in the Program, including, without limitation, costs, expenses and legal fees on a solicitor and his/her own client basis which RhPAP may incur in defending any claims or lawsuits that, or anyone on my behalf, may bring against RhPAP.


5. I understand and agree that this Agreement applies whether RhPAP is at fault or not.


6. I agree to abide by all applicable rules and requirements of the University of Alberta, the University of Calgary, the Alberta Health Services and the owner of facilities the Program may involve, and the rules and requirements of the RhPAP. The RhPAP rules and requirements of the Program are available for viewing at www.rhpap.ca/mentorship.


7. I understand that in securing the execution of this Agreement, RhPAP is acting as agent or trustee on behalf of or for the benefit of its respective employees, agents, officials, servants and representatives, whether paid or unpaid, who shall to this extent be, or be deemed to be, parties of this Agreement.


8. I allow RhPAP or its representatives to use, reproduce, publish, transmit, distribute, broadcast and display any photograph and/or video and/or audio recording that contains my image and/or voice along with my name in any RhPAP publication, multimedia production, video, CD-ROM, DVD, display, advertisement and/or on any of the corporate websites or other social media web sites without further notice or my approval of finished photographs and/or video and/or audio recordings.


9. I release RhPAP, Alberta Health and their contractors, agents, successors, assigns and licensees from all liability for any claim of infringement of publicity, privacy rights or compensation that I might otherwise have had in connection with the use of my name and likeness, or a representation of my likeness, including rights to any written copy that may be created in connection with video production, editing and promotion therewith.


10. This Agreement shall serve to benefit and bind RhPAP and myself and our respective heirs, executors, administrators, successors and assigns.

Please Read Carefully

The terms of this consent agreement govern the collection, use and disclosure of your personal information which you submit to the Alberta Rural Physicians Action Plan, operating as Alberta's Rural Health Professions Action Plan ("RhPAP").

The Purpose of Collection, Use and Disclosure

RhPAP may collect, use and disclose your personal information for the purposes of providing and administering the Rural Mentorship Program (“the Program”), including (without limitation):

1. Determining your eligibility for the Program and


2. Administering and evaluating the Program.

Personal Information Subject to Consent

Your personal information that will be collected, used, and disclosed by RhPAP for the purposes of providing and administering the Program includes:

1. Demographic information, including name, mailing address, email, and phone number and


2. Medical education information including university and year of medical school.

Withdrawal of Consent

You may withdraw or vary the terms of your consent in writing or electronically at any time. However, RhPAP may be unable to process your registration under the Rural Mentorship Program in the event that you withdraw or vary the terms of your consent. RhPAP reserves the right to refuse to process your registration in such an event.