Camp Lifeline Camper Application - Chai Lifeline Canada

July 29 – August 9, 2019

300 Atkinson Ave, Thornhill

(No camp Monday, August 5)

Step 1 of 6 - Camper Information

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Camp Information
Please attach a recent photo of your child*
Child Name*
First Last
Legal Name if Different from Above
First Last
Gender*
- Male
- Female
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Diagnosis*
Brief explanation of diagnosis
Treatment plan at camp
List medication, specific needs, special circumstances etc.
Other pertinent information we need to ensure a safe and healthy camp environment for your child

Family Information
Mother/Gaurdian Name*
First Last
Phone*
Cell Phone*
Email*
Father/Gaurdian Name*
First Last
Phone*
Cell Phone*
Email*
Emergency Contact*
First Last
Relationship to child*
Phone*
If we were able to offer it, would you be interested in early drop off?
- Yes
- No
Availability to be determined at a later date

Social and Behavioural Needs
Does your child understand and follow directions?*
- Yes
- No
- Sometimes
Please describe:
Does your child use age apropriate words to express needs and feelings?*
- Yes
- No
Please describe:
Does your child function at their age level?*
- Yes
- No
Please describe:

Consent and Release Form
For parents and/or legal guardians*
I understand
For Parents and/or Legal Guardians
This is a Legal Agreement, please review it carefully.

Our Child, whose names is set forth below, has applied to participate in Chai Lifeline’s Camp Lifeline and its related side trips, outings and activities (collectively referred to as “Camp Lifeline” or as “participating in Camp Lifeline”).

In exchange for giving our child the opportunity to participate in Camp Lifeline at no charge, in recognition of Chai Lifeline’s status as a community-based-not-for-profit organization, and in the event out Child participates in other Chai Lifeline programs currently or in the future, we acknowledge, understand and agree as follows:

That, while Chai Lifeline will endeavor to operate Camp Lifeline in accordance with generally accepted standards, it accepts no responsibility for the above Risks, unless damages to our Child are caused directly by the gross negligence of Chai Lifeline, or by the gross negligence of one of its employees, volunteers, agents or representatives (collectively, the “Agents”);
That we understand, accept, and assume any and all such Risks, on our own behalf, and on behalf of our Child
That we give our unqualified permission and our consent to Chai Lifeline to permit it to take our Child and have him/her participate in Camp Lifeline, and all of its related side trips, outings and activities, and authorize Chai Lifeline to exercise its discretion in the implementation of all aspects of Camp Lifeline and, specifically our Child’s participation in Camp Lifeline;
That we agree to release and hold harmless Chai Lifeline and its Agents from any claims costs, expenses and/or damages which our Child may sustain or incur as a result of participating in Camp Lifeline (collectively, the “Damages”), except to the extent that such Damages are directly caused by the gross negligence of Chai Lifeline or its Agents;
That routine medical needs and emergencies affecting our Child may arise during the course of Camp Lifeline (collectively “Medical Needs”), and that I may be impossible or impractical for Chai Lifeline or its Agents to reach us during the course of Camp Lifeline. We therefore agree and authorize Chai Lifeline and its Agents in advance and at all times during Camp Lifeline to use reasonable efforts and judgment:
To assess the Medical Needs of our Child and, if deemed necessary;
To seek medical treatment and/or services on behalf of our Child to address the Medical Needs including, but not limited to, the transport of our Child to secure medical treatment at emergency room and/or hospital, and to give consent on our behalf to medical professionals to authorize the treatment of our Child at such facilities
To provide a copy of this permission form to any and all treating medical professionals; and
To receive, transmit and exchange any and all medical information of any nature deemed reasonably necessary for the care of our Child to address the Medical Needs;
That we agree to accept full financial responsibility for any costs and expenses incurred by Chai Lifeline in connection with its efforts to attend to the Medical Needs of our Child and;
That while your Child is in Camp, he/she will most likely be photographed and videotaped several times a day. These photos are videos are used in several ways; internally in Camp, (including camp newsletter, videos, slideshow, photo books etc…)and on Chai Lifeline/Camp Lifeline web sites. Your Child is as precious to us as they are to you. All photos used with the understanding that there will be no exploitation of any child and that any photography and/or videotapes used will conform to standards of good taste.
Print Media Release*
- I agree
- I do not agree
I hereby authorize Camp Lifeline to interview and/or to have photographs, audio, or audiovisual recordings made of my child(ren) (hereinafter referred to as "Media Images"), and I authorize Camp Lifeline to display the media images for use on CHAI website, social media accounts, including, but not limited to Facebook, Twitter, and Instagram, as well as CHAI marketing material. I further authorize Camp Lifeline and fully understand and authorize Shining Stars to use the Media Images for all forms and manners, including, but not limited to, promotional videos in all forms of media, including publication in media forums including, but not limited to print, television, radio, and internet. I hereby release Camp Lifeline, directors, officials, employees, volunteers, and agents from any and all claims and demands arising out of or in connection with any use of the Media Images, including, without limitation, all claims for invasion of privacy, infringement, defamation and any other personal and/or property rights. I further acknowledge and agree that no sums of money or any consideration will be due to me as a result of the use of the photo/video material or any rights therein for Camp Lifeline publications.
Information regarding our Child*
First Middle Last
Please use child's legal name
That all of the information contained in this Agreement and on the attached Application, is true and complete to the best of our knowledge; That we have read this Agreement and fully understand its contents and are aware that we have waived legal rights, and have released Chai Lifeline on our behalf, and on behalf of our Child, and we sign it of our own free will; That we are the Parent(s) and/or Legal Guardians of the above named Child; That to the extent that our Child participates in our Chai Lifeline programs services, and/or events, currently or in the future, the provisions of the Parental/Legal Guardian Consent form are ongoing and will apply equally to such other Chai Lifeline programs and/or events as well.
Mother/Legal Guardian Name*
First Last
Signature*
Use your mouse or finger to draw your signature
Father/Legal Guardian Name*
First Last
Signature*
Use your mouse or finger to draw your signature

Step 1 of 6 - Camper Information

Camp Information

Family Information

Camper Information

Feeding and Dietary Needs

Allergies

Social and Behavioural Needs

Consent and Release Form