PHH Client Intake **

Refers to parent who is deceased

Please name someone other than parent/guardian

The Goal of Chai Lifeline Canada’s services are to provide support and care to children and families as they deal with the repercussions of serious paediatric illness. Unfortunately, some programs that Chai Lifeline provides may have certain inherent risks. Chai Lifeline Canada does do it’s best to mitigate this risk (e.g. volunteer screening) whenever possible, however there may be times when things circumstances are beyond our control.

In consideration of Chai Lifeline allowing my child’s participation in the activities of Chai Lifeline (the sufficiency of which is acknowledged), we release and forever discharge Chai Lifeline from all claims, demands, damages, actions or causes of action arising or to arise by reason of my child’s participation in the activities of Chai Lifeline, including, but not limited to, claims of harassment or abuse, and from all claims or demands whatever in law or in equity which we, our heirs, legal representatives or assigns can, shall or may have because of such use. And further in consideration of Chai Lifeline allowing my child’s participation in the activities of Chai Lifeline, we covenant to indemnify Chai Lifeline and its successors and assigns against all actions, damages, debts, accounts, claims and demands which may be brought against it by or on behalf of the above child because of such participation.

I hereby formally request and give full permission to Chai Lifeline (Canada) Inc. to provide programs and services to myself and my immediate family.

Permission is granted to Chai Lifeline Canada and it’s representatives to photograph any child/teen, and to use, publish, and release for publication, any photos taken at this program

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