Girls Cultural Camp Registration 2019 Registering YouthName:* First Last Age:*Gender* Date of Birth (mm/dd/yyyy)* MM slash DD slash YYYY Address:* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home Phone:*Mobile Phone*Alias (known by other name) Do you have an open file with Xyolhemeylh?* Yes No If yes, who is your social worker?* Email Address:* Band you belong to:* Check all that apply:* On Reserve Off Reserve Status Non-Status First Nations Metis Inuit Other If “other” please identify:* Please tell us why you want to go to camp. This will help the camp planning committee make decisions about who will be attending.*Yes, I, , agree to participate in all events and follow all rules and guidelines of Girls Cultural Camp.Youth Signature:**Above section must be completed by Youth Registering.Parent/Guardian InformationMother/Legal Guardian Full Name First Last Home Phone Number:Alternate Phone Number:Father/Legal Guardian Full Name First Last Home Phone Number:Alternate Phone Number:Signature of Parent/Guardian*Date:* MM slash DD slash YYYY Witness Name* First Last Witness Signature*Date:* MM slash DD slash YYYY Participation Permission Form:1. I hereby* Do Do not consent and authorize the Xyolhemeylh Summer Camp to use and reproduce photographs taken of my child and to circulate same for advertising or publicity purposes of every description. 2. It is our policy that we (Xyolhemeylh) notify a parent/guardian when a child is ill or needs medical attention. Occasionally, we are unable to contact parents/guardians and require immediate assistance for the child. Our procedure is to call an ambulance and transport your child to the nearest emergency center. 3. In the event of an injury or medical emergency, it is the policy of the Summer Camp Committee that the decision to call an ambulance (at the parent/guardian’s expense) rests with the trained staff on duty. 4. I hereby give consent for my child, , when ill or injured to be taken by ambulance to the nearest emergency center when I cannot be contacted. 5. I have provided the proper medical information and medical card number for my child. 6. I hereby give consent for Camp Staff to administer the following medications to my child, listed below. All medications must be in blister packs from the pharmacy with the original prescription label. All medications must be given to the camp staff upon arrival to camp. Medical InformationDoctor's Name* Doctor's Phone*Care Card #* Check All That Apply Allergic to bee/wasp stings Asthma Diabetes Recurring Headaches Seizures Black-Outs Chest Pain Heart Disease Mental Health Suicide Ideology Schizophrenia Other Other:* Does Your Child Swim?* Yes No Is Your Child Taking Any Medication?* Yes No (Please list medications below.)Does Your Child Have Any Special Needs?* Yes No Madication Incformation*Medication NameWhen It Is GivenAmount or DoseHow It Is Given Please identify any complex behaviours and/or developmental delays:Emergency Contact Information:Will you be available in case of emergency?* Yes No Please provide two emergency contact names and phone numbers we can call if there is an emergency:Contact Name #1:* Phone:*Contact Name #2:* Phone:*Signature Of Parent/Guardian*Date:* MM slash DD slash YYYY Please ensure your child is free from any communicable diseases or contagious diseases (examples: flu, scabies, pink eye, strep throat, head lice, etc) If your child arrives at camp with a communicable disease they will be sent home.Additional InformationTell us anything else you'd like us to know.Girls Cultural Camp Code of ConductThis contract must be signed and dated by the camp participant and a parent/legal guardian. This contract is designed to help participants and parents/guardians understand the expectations of the participants of Girls Cultural Camp. Please read carefully, sign and date this form then return to Xyólheméylh attention Summer Camps with the completed registration form, participant permission form and waiver form. I, , agree to abide by the following: I will promote a positive, productive, and supportive environment for the group. I will notify the Camp Leaders or Xyólheméylh employees of any injury or illness. I will refrain from using foul and demeaning language. I will not use any alcohol, cigarettes or drugs other than medication prescribed to me by a doctor. I understand that if I use alcohol, cigarettes or drugs I will be sent home as soon as possible at my own expense. I understand that under NO CIRCUMSTANCES will males be permitted into the Girls Cultural Camp and under NO CIRCUMSTANCES will females be permitted into the Boys Cultural Camp. The only exception is the Slahal game. I understand that it will be the decision of the Camp Leaders or Xyólheméylh employees that if any term of this contract is broken I will be sent home immediately. I understand that my Parents/Guardians/Emergency Contact persons will be contacted AT ANY TIME of the day or night in the event I am returning home due to an emergency or failure to abide by the Code of Conduct or Camp Guidelines. I, , Camp Registrant, have read and understand all of the forms provided. I acknowledge and accept full responsibility as described above. Signature of Youth Registering:*Please draw your signature within the box.Signature of Parent Guardian:*Please draw your signature within the box.Date:* MM slash DD slash YYYY WaiverWAIVER & RELEASE OF LIABILITY: In the consideration of the Indigenous Sport, Physical Activity and Recreation Council (ISPARC) accepting my registration and allowing me to participate in the High 5 Training, Introduction to Canoeing, Lacrosse and/or Archery Sessions as part of the Fraser Valley Aboriginal Children and Family Services Society 2019 Summer Camps, I myself, my heirs, executors, administrators and assigns hereby agree to: RELEASE the BC Association of Aboriginal Friendship Centers (as the host organization of the ISPARC) Fraser Valley Aboriginal Children and Family Services Society (event hosts), Indigenous Sport, Physical Activity and Recreation Council, its partners, volunteers, servants, agents, employees and other participants of the event (all of whom are hereinafter collectively referred to as the “Releases”), from any and all claims, actions, costs, demands and expenses arising out of or in consequence of any loss, injury or damage to my person or personal property incurred while attending at or participating in the High 5 Training, Introduction to Canoeing, Lacrosse and/or Archery Sessions, notwithstanding that any such loss, injury or damage may result from the negligence of the Releases. In addition, permission is granted to administer any medical treatment that may be required. WAIVE ANY AND ALL CLAIMS that I, my heirs, executors, administrators, insurers, successors and assigns have or may have in the future against the Releases. I understand the rules and regulations are designed for the safety and protection of participants and hereby agree to abide by the rules, regulations set by the ISPARC and BC Association of Aboriginal Friendship Centers. I have read this release of liability and assumption of risk agreement, and fully understand its terms. I understand that I have given up substantial rights by signing it, and sign freely voluntarily, without an inducement.Participant Signature*Witness*PARENT/LEGAL GUARDIAN - For participants under the age of 19 the following must be completed by his/her parent or guardian. I, as the parent/legal guardian of the participant named above and herein, agree to assume the full responsibility to instruct my child of the risks involved, and to inform him/her of the importance of abiding by the rules and regulations of the Camp. I, as the parent/legal guardian of the participant named herein, hereby declare that I have read, understood and agree to the contents of this Waiver and Release of Liability in its entirety.Parent/Guardian Name* Signature*This information is being collected in accordance with the Municipal Government Act and is protected by the privacy provisions of the Freedom of Information & Protection of Privacy Act (R.S.A 2000 c, F-25). Any questions about the collection and use of information, please contact the Director of the Indigenous Sport, Physical Activity and Recreation Council at 604-388-5522.NameThis field is for validation purposes and should be left unchanged. Δ
