Deaf Youth British Columbia RETREAT 2015

Registration Fees will be paid through PayPal and must be completed in order to complete registration process online. YOU DO NOT need to have a PayPal account to use this system and may use credit card or debit card. If you do not have a Paypal account you may sign in as a "guest".

Only one camper may be registered at a time.

Camper's Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Birth Date - MUST BE AGE 19 - 30 TO REGISTER*

MonthDayYear

Current Age:*

MaleFemaleN/A

Phone Number*

Area CodePhone Number

E-mail*

NO, I do not need Deaf InterpreterYES, I do need Deaf Interpreter

Please provide at least 2 emergency conacts.

1st Emergency Contact Name*

First NameLast Name

1st Emergency Contact Relationship:*

1st Emergency Contact Daytime Phone Number:*

Area CodePhone Number

1st Emergency Contact Evening Phone Number if different:

Area CodePhone Number

2nd Emergency Contact Name:*

First NameLast Name

2nd Emergency Contact Relationship:*

2nd Emergency Contact Day Phone Number:*

Area CodePhone Number

2nd Emergency Contact Evening Phone Number if different:

Area CodePhone Number

Please list other important emergency contacts, their relationship to camper, best phone numbers or other contact information that will be helpful in an emergency.

Doctors Name or Medical Clinic:*

Doctor's Phone Number:

Area CodePhone Number

List any medical food allergies: (If none, enter none)*

List any chronic illness and or physical limitaitons camp should know about: (If none, enter none)*

List all current medications: (If none, enter none)*

Personal Health Number*

I, undersigned, understand and acknowledge that the Deaf Youth British Columbia Retreat and its associated activities in which I am to engage as a participant and/or volunteer from June 12th to June 14th 2015 (inclusive) generate risk that may result in injury, death, illness, or property damage to myself, other participants,spectators, or other third parties.

Acceptance of Risk and Responsibility

I hereby agree to release any liability and accountability on the part of Deaf Youth British Columbia, its committee, members and sponsors, for the duration of the Deaf Youth British Columbia Retreat, June 12th to 14th 2015 in White Rock, British Columbia.

This includes any and all occurrences on and off the campsites, and during activities pertaining to Deaf Youth British Columbia with or without alcohol. I also agree to abide by any local, provincial and federal laws pertaining to any other illegal substances and/or laws related to the legal drinking age.

I understand it is my responsibility to make sure that the Committee is aware of any food or environmental allergies I may have. The Committee will be sensitive with creating meals and alternate meals where necessary but will not be directly responsible for creating separate menus.

I sign this with the knowledge that I am responsible for my own actions and will not hold Deaf Youth British Columbia, its committee, its members or its sponsors responsible for any events that may or may not occur.

Permission to Act on My Behalf in Case of Emergency

If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of Deaf Youth British Columbia to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that Deaf Youth British Columbia only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness.

Photo Waiver

I furthermore understand Deaf Youth British Columbia often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of Deaf Youth British Columbia. Deaf Youth British Columbia will not identify me or my child by name, or release any other personal information without additional written permission from me.

Electronic Signature: By entering my name below, I accept the above conditions and releases. *

First NameLast Name

Current Date:*

MonthDayYear

My Products

Deaf Youth British Columbia Retreat Registration$50.00CAD

For Security, type the message seen below:*

An 80% refund of camp fee is made if notice is given to Deaf Youth British Columbia by May 12, 2015. A 50% refund is made if notice is given to Deaf Youth British Columbia no later than the beginning of that camp. No refund will be made once the camp starts.

Please note: T-shirt purchase and PayPal Fee are not refundable.

All refunds are processed after the camp ends. We do not prorate fees for attending only a part of the camp week.

Upon completion of filling in all areas of form, click "Submit Form". You will then be taken to PayPal where you will pay and registration process will be completed. Only one camper may be registered at a time. You may click "Print Form" to print a copy of this form. Do you have questions or need help with online registration? Email Scott at Scott@deafyouth.ca

Deaf Youth British Columbia's Retreat 2015

Emergency and Medical Information

Liability/Photo/Video Release

Payment

Refund Policy