PHH Disney Application - Chai Lifeline Canada

This application must be completed by a parent or guardian .

Step 1 of 6 - Intro

To fill out the application, you will need:
1) A digital copy of your health insurance card
2) A digital copy of your child's prescription card (if necessary)

Hidden
Personal Information:
Title
Legal Name on Passport*
First Last
What is the name you call your child everyday?*
Email*
Cell Phone*
Home Phone
Address*
Street Address City Province Postal Code
Date of Birth*
Age*
Gender*
- Male
- Female
Custodial Parents or Legal Guardians:
Mother's Name
First Last
Cell Phone
Email
Father's Name
First Last
Cell Phone
Email
Legal Guardian (if other than parent)
First Last
Phone Number
Persons to be contacted in case of emergency:
Name*
First Last
Relationship to Child*
Home Phone*
Cell Phone*
Work Phone*
Email*

Shirt Sizing
We give each child three colourful t-shirts (one for each day of the trip). Wearing these shirts is mandatory.
Select the most apropriate size for your child:*
- Child Small
- Child Medium
- Child Large
- Adult Small
- Adult Medium
- Adult Large
- Adult Extra Large
- Adults Extra Extra Large

Consent and Release Form
Our Child, whose name is set forth below, has applied to participate in Chai Lifeline / Penina's Helping Hand, and its related side trips, outings and activities (collectively referred to as "Chai Lifeline/PHH" or as "participating in Chai Lifeline/PHH").

In exchange for giving our Child the opportunity to participate in Chai Lifeline/PHH at no charge, in recognition of Chai Lifeline's/PHH programs currently or in the future, we acknowledge, understand and agree as follows:
1. That traveling to or from Chai Lifeline/PHH Disney Trip, and participating in Chai Lifeline/PHH, has several inherent risks, and that our child may be exposed to a wide range of risks including but not limited to: the risk of accidents, bodily injuries, unforeseen events, emergency heath problems, risks associated with the need for routine or emergency medical or other support services provided by Chai Lifeline/PHH Medical Team, or by others (all of whom may, or may not, be familiar with our child's medical history and/or needs), and/or the loss or damage to our child's property (collectively, the "risks")
2. That, while Chai Lifeline/PHH will endeavor to operate the Disney Trip 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/PHH, or by the gross negligence of one of its employees, volunteers, agents or representatives (collectively, the "agents");
3. That we understand, accept, and assume any and all such risks, on our behalf, and on behalf of our child;
4. That we give our unqualified permission and consent to Chai Lifeline/PHH to permit it to take out child and have him/her participate in Chai Lifeline/PHH, and all of its related side trips, outings and activities, and authorize Chai Lifeline/PHH to exercise its discretion in the implementation of all aspects of Chai Lifeline/PHH and, specifically, our child's participation in Chai Lifeline/PHH Disney Trip;
5. That we agree to release and hold harmless Chai Lifeline/PHH and its Agents from any claims costs, expenses and/or damages which our Child may sustain or incur as a result of participating in Chai Lifeline/PHH (collectively, the “Damages”), except to the extent that such Damages are directly ca used by the gross negligence of Chai Lifeline/PHH or its Agents;
6. That routine medical needs and emergencies affecting our Child may arise during the course of the Chai Lifeline/PHH Disney Trip (collectively “Medical Needs” ), and that it may be impossible or impractical for Chai Lifeline or its Agents to reach us during the course of the Disney trip. We therefore agree and authorize Chai Lifeline and its Agents in advance and at all times during the Disney trip to use reasonable efforts and judgment:
  1. to assess the Medical Needs of our Child and, if deemed necessary;
  2. 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;
  3. to provide a copy of this permission form to any and all treating medical professionals; and
  4. 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;
7. 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
8. That while our Child is on the trip, he/she will most likely be photographed and videotaped several times a day. These photos and videos are used in several ways: internally for the trip, our semi-annual magazine that goes to Chai Lifeline parents and supporters, in print advertisements placed in Jewish media and on Chai Lifeline web sites. Your Child is as precious to us as they are to you. For this reason, please check off those areas where you will allow Chai Lifeline to utilize your Child’s image. All photos are used with the understanding that there will be no exploitation of any child and that any photographs and/or videotapes used will conform to standards of good taste.
Consent*
Check here if full permission and authority is granted to Chai Lifeline and its representatives to photograph and/or videotape my Child and to use, publish, and release for publication, such photos relating to Chai Lifeline/ PHH programs.
Consent*
Check here if if permission is granted for internal trip use including the trip newsletter, newspaper, online picture gallery, slideshow, yearbook, video, dvd, etc.
Legal Name*
First Last
Child's Date of Birth*
MM slash DD slash YYYY
1. That all of the information contained in this Agreement and on the attached Application, is true and complete to the best of our knowledge;
2. 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;
3. That we are the Parent(s) and/or Legal Guardians of the above named Child;
4. That, in the event the Child referenced in this Agreement is 18 years of age or older, he/she agrees to be bound by all of the terms of this Agreement as well; and
5. That, to the extent that our Child participates in other Chai Lifeline/PHH programs services, and/or events, currently or in the future, the provisions of this Parental / Legal Guardian Consent form are ongoing and will apply equally to such other Chai Lifeline/PHH programs and/or events as well.
Father Signature
Father Name
First Last
Date
MM slash DD slash YYYY
Mother Signature
Mother Name
First Last
Date
MM slash DD slash YYYY
Legal Guardian Signature
Legal Guardian Name
First Last
Date
MM slash DD slash YYYY
Child Sign if over 18 Years old
Child Name
First Last
Date
MM slash DD slash YYYY

Medical Financial Responsibility Agreement
I agree to accept full financial responsibility for all medical costs incurred on behalf of my child while on the Chai Lifeline - PHH Orlando Trip, including, but not limited to, any routine and/or emergency laboratory tests, medical, surgical, ambulance services, prescription or non-prescription drugs and/or hospital costs. In the event that my insurance carrier will not cover any or all medical costs or that any hospital requires a deposit, I agree to take full responsibility for all costs. PLEASE CHECK WITH YOUR INSURANCE CARRIER TO ASCERTAIN COVERAGE IN THE STATE OF FLORIDA. IN THE EVENT THAT YOUR COVERAGE DOES NOT EXTEND OUT OF STATE, PLEASE CALL US.
Child's Name*
First Last
Person Assuming Responsibility*
Relationship to Child*
Phone*
Signature*
Date*
MM slash DD slash YYYY
Insured's Name*
First Last
Carrier*
Policy Number*
Attach Copy of Insurance Card*
Drop files here or

Max. file size: 50 MB.
Please include front and back images
Attach Copy of Prescription Card
Drop files here or

Max. file size: 50 MB.
Please include front and back images

Step 1 of 6 - Intro

To fill out the application, you will need:

Personal Information:

Custodial Parents or Legal Guardians:

Persons to be contacted in case of emergency:

Medical History:

Allergies: Use "none" when applicable

My Child Can...

Shirt Sizing

Consent and Release Form

Medical Financial Responsibility Agreement