Event Registration Form - Chai Lifeline Canada

Chai Lifeline Canada Branch?*
Event Name*
Please fill in "Cottage Day"
Family Name*
Who is your Family Case Manager?
How many are attending in total? (including adults)*
Email*
Enter Email Confirm Email
Phone/Cell*
Guardian/Parent*
First Last
Who will be attending the event?
Name of Child and Age*
Would you like to request a volunteer?*
- Yes I need a volunteer
- No I do not need a volunteer
Do you require transportation?*
- Yes I need a ride
- No I do not need a ride
Limited availability - Please let us know if you need transportation and we will do our best to accomodate
Comments
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.
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.
Signature*
Use computer mouse or finger to sign
Name of Signature*
First Last
Please type the first and last name of person who signed
Date*
Date Format: DD slash MM slash YYYY