Caregiver Camp Registration 2019 Registering CaregiversFirst Registering Caregiver:* First Last Second Registering Caregiver : First Last Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone:*Cell Phone:Email Address:* Emergency Contact InformationEmergency Contact Name:*Emergency Contact Phone:*Family & Child InformationTotal Number of Family Members Attending (including caregiver):*Please enter a number from 2 to 12.Will you be attending all three days at camp?*YesNoWill you be attending the day camp only?*YesNoFood Allergies?Children Information:*Participant's First & Last NamesAge (at camp)Social WorkerGender Enter up to 10 children.Caregivers are responsible for children through camp duration with support from staff and committee.Camp Code of ConductThis contract must be signed and dated by the registering caregiver(s). This contract is designed to help participants understand certain expectations of the Caregiver Camp. Please read carefully, sign, date and return to Xyolhemeylh attention “Caregiver Camp” with your completed registration form. I, and , agree to abide by the following: My family and I will promote a positive, productive, and supportive environment for the group. My family and I will notify the Camp Leaders or Xyolhemeylh employees of any injury or illness. My family and I will refrain from using foul and demeaning language, whether in public or in a group. My family and I will be in camp at the times specified and remain there unless otherwise authorized. My family and I will not use any alcohol, drugs or other substances. I understand that if alcohol, drugs or other substances are used we will be sent home immediately at my family’s expense. I also understand that I will not be reimbursed any trip costs. My family and I understand that it will be the decision of the Camp Leaders or Xyolhemeylh employees that if any item of this contract is broken my family will be sent home immediately, at our own expense. I also understand that we will not be reimbursed any trip costs. I understand there are no family pets allowed at Caregiver Camp. I, , Caregiver Registrant, have read and understand all of the forms provided. I acknowledge and accept full responsibility for my family as described above.Signature of First Family Registrant:*Please draw your signature within the box.Date:* Date Format: MM slash DD slash YYYY I, , Caregiver Registrant, have read and understand all of the forms provided. I acknowledge and accept full responsibility for my family as described above.Signature of Second Family Registrant:*Please draw your signature within the box.Date:* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
