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Camp Lifeline Away Camper Application

Step 1 of 6 - Camper Information

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  • Camper Information

  • Max. file size: 50 MB.
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    List medication, specific needs, special circumstances etc.
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  • Family Information

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    Availability to be determined at a later date
  • Camper Information

  • Please provide your child’s day camp and overnight camp history.
  • Sports, painting, crafts, specific games etc
  • ie ADD/ADHD, anxiety, depression, severe asthma, anaphylaxis, diabetes, epilepsy, history of self harm, eating disorder
  • Would they be able to walk for 10 minutes or would they need a stroller?
  • Please specify amounts, how often, etc
  • Feeding and Dietary Needs

  • Allergies

  • Social and Behavioural Needs

  • Consent and Release Form

  • 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.
    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 Camp Lifeline 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.
  • 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.
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Toronto

300A Wilson Ave.
Toronto, Ontario, M3H 1S8
Phone: 647.430.5933
Fax: 416.628.1597

Montreal

1090B Pratt
Montreal, Quebec, H2V 2V2
Phone: 514.667.7041

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At Chai Lifeline Canada we are passionately devoted to alleviating the burden of those facing medical challenge. From the moment of diagnosis, through the arduous months and years, in good times and bad, Canadian families have discovered that Chai Lifeline Canada is a friend for life.

Chai Lifeline Canada. Fighting Illness with Love.

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Chai Lifeline Canada is a registered Canadian charity
Reg. No. 85656 5536 RR0001

Chai Lifeline Canada is a member of the OCGA

©2020 Chai Lifeline Canada. All rights reserved. Design & Development by LeverageIT

©2023 Chai Lifeline Canada. All rights reserved. Design & Development by LeverageIT. Chai Lifeline Canada is a registered Canadian charity. Reg. No. 85656 5536 RR0001. Chai Lifeline Canada is a member of the OCGA
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  • About Us
    • Who We Are
    • Our Values
    • Our Team
    • Contact Us
  • What We Do
    • What We Do
    • News and Media
      • Videos
  • How You Can Help
    • Annual Campaign
    • Birthday in a Box
    • Clothing Bin Program
    • Donate a Car
    • Ecards
    • Hair Donation Program
    • Start Your Own Fundraiser
      • Bnei Mitzvah Program
      • Party With A Purpose
      • Stand for Chai
    • Toy Drive & Chanukah Heroes
      • Amazon Wish List
    • Young Builders
      • Come Say Chai
  • Family Resources
    • Autism Resources
    • Bereavement & Counselling Support
    • Chronic Illness Resources
    • Financial Resources
    • Kids’ Lifeline
    • Mental Health Resources
    • Chai Lifeline Forms and Applications
  • Careers & Volunteers
    • Employment Opportunities
    • Volunteer Hub
      • Volunteer Forms

Toronto

300A Wilson Ave. Toronto, Ontario, M3H 1S8

Phone: 647.430.5933

Montreal

1090B Pratt. Montreal, Quebec, H2V 2V2

Phone: 514.667.7041

Crisis Intervention

Email: [email protected]

Phone: 1 (800) 556-6238

  • About Us
    • Who We Are
    • Our Values
    • Our Team
    • Contact Us
  • What We Do
    • What We Do
    • News and Media
      • Videos
  • How You Can Help
    • Annual Campaign
    • Birthday in a Box
    • Clothing Bin Program
    • Donate a Car
    • Ecards
    • Hair Donation Program
    • Start Your Own Fundraiser
      • Bnei Mitzvah Program
      • Party With A Purpose
      • Stand for Chai
    • Toy Drive & Chanukah Heroes
      • Amazon Wish List
    • Young Builders
      • Come Say Chai
  • Family Resources
    • Autism Resources
    • Bereavement & Counselling Support
    • Chronic Illness Resources
    • Financial Resources
    • Kids’ Lifeline
    • Mental Health Resources
    • Chai Lifeline Forms and Applications
  • Careers & Volunteers
    • Employment Opportunities
    • Volunteer Hub
      • Volunteer Forms
Menu
  • About Us
    • Who We Are
    • Our Values
    • Our Team
    • Contact Us
  • What We Do
    • What We Do
    • News and Media
      • Videos
  • How You Can Help
    • Annual Campaign
    • Birthday in a Box
    • Clothing Bin Program
    • Donate a Car
    • Ecards
    • Hair Donation Program
    • Start Your Own Fundraiser
      • Bnei Mitzvah Program
      • Party With A Purpose
      • Stand for Chai
    • Toy Drive & Chanukah Heroes
      • Amazon Wish List
    • Young Builders
      • Come Say Chai
  • Family Resources
    • Autism Resources
    • Bereavement & Counselling Support
    • Chronic Illness Resources
    • Financial Resources
    • Kids’ Lifeline
    • Mental Health Resources
    • Chai Lifeline Forms and Applications
  • Careers & Volunteers
    • Employment Opportunities
    • Volunteer Hub
      • Volunteer Forms

Toronto

300A Wilson Ave. Toronto, Ontario, M3H 1S8

Phone: 647.430.5933

Montreal

1090B Pratt. Montreal, Quebec, H2V 2V2

Phone: 514.667.7041

Crisis Intervention

Email: [email protected]

Phone: 1 (800) 556-6238