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Section One: General Camper Information Camper Info
Camper Date of Birth

Camper Provincial Health Card Info
Camper Private Health Card Info
Camper Health Card Expiry
Camper Private Health Policy Expiry

Camping History
Parent(s) / Guardian(s) Contact Info
Parent / Guardian 1
Parent / Guardian 2
Please complete all mandatory fields
Section Two: Medical Information Please fill in the details below. Six weeks prior to camp we will reconfirn these medical details with you, to ensure this info is up-to-date.
Chronic Medical Conditions

Current Medical Conditions

Allergies

recent injuries or surgeries:

Dietary Restrictions:
Does the camper have difficulty:

Medication Form Please detail the camper’s medication regimen. Please be specific and include all medications (including over the counter medications) that the camper takes, as well as when they should be administered.
Please complete all required fields
Section Three: Personal Devices / Aplliances Please identify whether the camper has or uses any of the following medical/ optical/ orthodontic/ respiratory/ mobility devices with them at camp:
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Section Four: Behavioural Information Does this camper require one-on-one support with any of the following?
Please identify any types of behaviour that apply to the camper:
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Section Five: Background Information
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Section Six: Emergency Contact Information Please list two people (other than parent/guardian) that can be contacted in the event a parent/guardian cannot be reached:
Emergency Contact 1
Emergency Contact 2
CUSTODIAN INFORMATION Who has legal custody of the camper?
Please complete all required fields
Section Seven: Travel Information and Travel Consent Please select your preference. Please understand that we will do our best to connect those who are offering/needing carpooling, however, it is ultimately the parent/guardian’s responsibility to get the camper to our drop-off/pick-up location or the camp facility itself.
If you selected the last option, please fill out the following information.
Note: the assigned adult must bring photo ID to pick up the camper.
Please complete the required fields
Section 8: Payment Thank you for completing this application. A full invoice will be sent to to you via email, once your application is approved. All early bird specials and subsidies will be applied to the invoice.
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Who should we contact to process the payment for this registration?

I, being the parent and/or legal guardian for my child that is registered for Camp Trailblazers, hereby assign all rights to AboutFace Craniofacial Family Society (“AboutFace”), for use of the materials I have released, including but not limited to film/ videotape/ photographs/ sound recording/ text copy concerning my child made by/ for the exclusive use of AboutFace.

I hereby authorize the use of the same by AboutFace., and those acting with its permission, for the purpose of illustration, publication, broadcast or other uses in connection with the charitable work of AboutFace.. I hereby release AboutFace. and those acting with its permission from any liability, claims and causes of action arising in connection with the use of the materials [or any modification thereof.] All materials remain the property of AboutFace.
The information provided is a complete and accurate statement of the physical and psychological (mental health) factors that may affect participation at the Teen Retreat for the participant, if under 18 years of age, or for myself, if 18 years of age. I realize that failure to disclose such information could result in harm to the person named below/myself or fellow participants and agree to indemnify and hold AboutFace and its directors, officers, employees, agents and affiliates, harmless from any and all loss, injury or damage incurred by them if all relevant information is not disclosed, and I release AboutFace from any liability for any harm sustained by the participant/myself arising from my failure to fully disclose such information.

To the best of my knowledge this participant is/I am in good physical and mental health and has/have not been exposed to any infectious disease in the past four weeks. If he/she or I become(s) exposed to any infectious disease between now and the time of departure for the Teen Retrest or has any change in their/my physical or mental health I will notify AboutFace in writing. In the case of surgical or medical emergency or a critical mental health emergency, and we are not available for consultation or my emergency contact is not available, I hereby give permission to the Physician at the hospital where this participant is/I am receiving care to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for the above named participant/myself.

The information provided is a complete and accurate statement of the physical and psychological (mental health) factors that may affect participation at the Teen Retreat for this participant/mself. I realize that failure to disclose such information could result in harm to the person named below/myself or fellow paticipants and agree to indemnify and hold AboutFace and its directors, officers, employees, agents and affiliates, harmless from any and all loss, injury or damage incurred by them if all relevant information is not disclosed, and I release AboutFace from any liability for any harm sustained by the participant/myself arising from my failure to fully disclose such information.

I also authorize the participant's/my family physician or specialist who may be currently treating the participant/myselt to release any medical information concerning the participant's/my previous or current physical and mental health history or condition to the AboutFace staff staff and/or Physician selected by them to treat the participant/myself pursuant to the authorization given herein.

Note: Mental health includes any significant events over the last six months which may include hospitalization, suicide attempts, self-harm or psychiatric care. AboutFace staff take any threats or acts of suicide or self-harm or harm of fellow participants very seriously. If these become an issue for your child, parents/guardians will be contacted by AboutFace staff and your child will be taken to the nearest, appropriate medical facility.

Enrollment is subject to the following terms and conditions. A formal acceptance, based on space will be made to the parent (or guardian) to confirm enrollment, or directly to the participant if 18 years of age or older. Your enrollment is not complete until the acceptance has been sent. We will send a confirmation by email.

There will be no reduction in or refund of fees for any reason with less than five weeks’ notice prior to the start date, including, without limitation for:

1. A participant who cancels or withdraws from the program whether prior to or during the period for which they are registered;
2. A participant who arrives late or leaves early in the period for which they are registered; or
3. A participant who is expelled, withdraws or is removed from the Teen Retreat for breaking the rules, for a physical and/or mental health emergency, or otherwise.

AboutFace will not be responsible for any loss or theft of or damage to the participant's property.

Unless I advise you otherwise in advance in writing, I approve the participant's/my participation in all the programs and activities for the Teen Retreat, and acknowledge that such participation involves risks and hazards incidental thereto, all of which are expressly assumed by me.

I hereby waive, release and absolve and agree to indemnify and save harmless AboutFace and its directors, officers, employees, agents and affiliates of and from any and all liability arising from the participant's/my attendance at the Teen Retreat, except such as shall arise solely as a consequence of its or their willful negligence or willful default. If, for any reason, the participant/I require(s) medical attention or special medication beyond that furnished by the retreat, I agree to be responsible for any expenses incurred. I hereby consent to AboutFace and their partners using any photos and videos taken of my child/myself and my child’s/my name in its promotional materials including, without limitation, web based materials, social media, print materials and advertisements.
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Your application has been submitted successfully. Thank you.


Please contact Emily RiversEmily Rivers (danielle@aboutface.ca) if you have any questons.


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Please contact Emily RiversEmily Rivers (danielle@aboutface.ca) if you have any questons.