Henryk Sienkiewicz Polish School Camp Application Form

Polska Szkola im. Henryka Sienkiewicza Henryk Sienkiewicz Polish School

Henryk Sienkiewicz Polish School Camp Application Form One week camp organized by Henryk Sienkiewicz Polish School Parents Association in Edmonton at Polish Scouts Camp "Kopernik", Garner Lake (140km east of Edmonton), Alberta. Arrival: July 13, 2013 Departure: July 21, 2013 Parents are responsible for organizing transportation to and from the camp. We accept children from 9 to 16 years of age. Cost: $300.00/child (students of Henryk Sienkiewicz Polish School), $400.00/child (others)

Name of Participant: __________________________________________________________ Date of Birth: _______________________ Name of Parents/Guardians: ____________________________________________________ Address: ____________________________________________________________________ Phone Numbers: ________________________________________________________________ Emergency Contact(Name): ________________________________ ph# ___________________

Medical Information. Alberta Healthcare # _________________________ Allergies: food ___________________________________________ others __________________________________________ Any other health conditions: ____________________________________________________ ____________________________________________________

12140-103 Street * Edmonton, AB, Canada * Tel: (780) 454-0205 http://www.pshs.ca

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Medical Authorization I authorize any medical or emergency treatment should the Participant become ill or involved in an accident during the camp from July 13 - 21, 2013. Photographic Release I do____/do not____ authorize the Henryk Sienkiewicz Polish School Camp employees to take pictures of my child during his/her activities at the Henryk Sienkiewicz Polish School Camp which might be used for advertising or publicity purposes, or be posted on the school’s website. Inherent Risk Camping is an activity with physical demands and inherent risks which are beyond the control of the Henryk Sienkiewicz Polish School Parents Association. In spite of precautions and supervision of activities by trained counsellors camping and other accidents may occur and cause injury. In order to participate Participant must assume the risks and dangers. Waiver/Release of Liability In consideration of the Participant being permitted to participate in the Henryk Sienkiewicz Polish School Camp, I, for myself, my heirs, executors, administrators and assigns release Henryk Sienkiewicz Polish School Parent Association, its employees and other organizers, sponsors, representatives, their agents, directors and employees and any other person or their heirs, executors, administrators, successors and assigns, or organizations assisting from all claims, demands, damages, actions or causes of actions, arising out of or in consequence of any loss, injury or damage to the Participant or property incurred while participating in the Henryk Sienkiewicz Polish School Camp.


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I being one of the parents/guardians of the Participant, do hereby consent to the Participant's involvement in the Henryk Sienkiewicz Polish School Camp and agree to the terms of Waiver of Liability, Medical Authorization and Photographic Release.

_____________________________________________ Signature of Parent/Guardian

________________________ Date

Participant's Code of Conduct Each Participant of the camp shall respect the authority of the camp counsellors and instructors and demonstrate willingness to cooperate at all times to ensure the physical and mental wellbeing of other Participants and camp staff. Persistent opposition to authority, willful destruction of property, the use of profane or inappropriate language or conduct injurious to the moral tone of the programme will result in the loss of the privilege to participate in the camp. I, the Participant, have read and understood the above rules of conduct and agree to them. If do not respect these regulations while I participate in the camp, my parents will be notified and I will be sent home at their expense.

__________________________________________

_______________________

Signature of the Participant

Date


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