Event Registration Form - Chai Lifeline Canada

Registration Is Closed.
Event at Capacity

Chai Lifeline Canada Branch?*
Event Name*
First Name*
Last Name*
Who is your Family Case Manager?
Please let us know your families numbers!*
Child: 2 And Younger Child: 3 - 12 Years Old Young Adult: 13 - 17 Years Old Adult: 18 - 64 Years Old Senior: 65+
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How many children are attending?
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How many adults are attending?
Phone/Cell*
Email*
Enter Email Confirm Email
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Select Time Slot
- Select All
- 1:00 PM - 2:00 PM
- 2:30 PM - 3:30 PM
Please let us know your choice of time you would like to attend. Please select as many as your available for. We will do our best to accommodate.
Comments
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Consent Agreement
The following consent agreement must be signed by parent or a legal guardian: I understand that unless I have detailed any specific restrictions to activities on this form, I accept full responsibility for my child’s/children’s safety. I agree to release and hold harmless CHAI LIFELINE CANADA and all of their representatives and volunteers from any claims, costs, expenses and/or damages which I or my child/children may sustain or incur by joining. In the event of any lawsuits or claims for damages against CHAI LIFELINE CANADA, their representatives or volunteers, I agree to identify and hold harmless CHAI LIFELINE CANADA and their representatives for any damages arising from such claims.
Do You Need a Volunteer?
- Yes
- No
PLEASE KEEP IN MIND: We will do our best to provide you with a volunteer, but we cannot guarantee.
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Photo Release*
- Yes, We are released
- No, We are not Released
Full 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 event.
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Signature
Use computer mouse or finger to sign
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Name of Signature*
First Last
Please type the first and last name of person who signed
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Date*
DD slash MM slash YYYY

Registration Is Closed.
Event at Capacity

36 HOURS.

$500,000

2X MATCH!

Minimum $18 donation per tribute card

Registration Is Closed. Event at Capacity

36 HOURS.

$500,000

2X MATCH!

Minimum $18 donation per tribute card

Registration Is Closed.
Event at Capacity