Family Spirit Camp Registration 2019 Registering Family MemberName:* First Last Age:*Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Address:* Do you have access to the internet?* Yes No Do you have an open file with Xyolhemeylh?* Yes No Check all that apply:* On Reserve Off Reserve Status Non-Status Metis Inuit Other Band you belong to:* Home Phone:*Cell Phone:Okay to text?* Yes No Family Information:*Participant First & Last NameRelationship? (Husband, Wife, Child, Aunt, etc.)CIC? Y or NAgeDietary RestrictionsGender Enter up to 10 family members.If you are currently receiving services from Xyólheméylh, please identify your social worker: Emergency Contact Information:Please provide two emergency contact names and phone numbers we can call if there is an emergency:Name:* Phone:*Relationship:* Name:* Phone:*Relationship:* Social Workers: Please note, if there is a supervision order in place for your family you must attend camp with your family all three days.Medical InformationHiddenNumber of Rows*Please enter a number from 15 to 15. Family Spirit Camp Code of ConductThis contract must be signed and dated by the registering family member. This contract is designed to help participants understand certain expectations of the Family Spirit Camp. Please read, sign and date this form then return with your completed registration package. I, , 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, within our group or toward any person. 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 or drugs, other than those prescribed by a doctor. I understand that if I or anyone in my registered group use alcohol or drugs, I/they will be sent home immediately, at my/their own expense. I also understand that I will not be reimbursed for any transportation 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 I/we will be sent home immediately at our own expense. We also understand that I/we will not be reimbursed any transportation costs. I, , Family Registrant, have read and understand all of the forms provided. I acknowledge and accept full responsibility for my family as described above. Signature of Family Registrant:* Reset signature Signature locked. Reset to sign again Please draw your signature within the box.Date:* MM slash DD slash YYYY Photographic WaiverConsent:* We hereby do consent and authorize Xyolhemeylh to use and reproduce photographs taken of above registered camp participants and to circulate same for advertising or publicity purposes of every description. We do not allow any photographs to be taken. Printed Name:* First Last Signature:* Reset signature Signature locked. Reset to sign again Please draw your signature within the box.Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
