2019 Gilda's Club Chicago Summer Camp Application

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**Si usted hablas español podemos ayudarle a completar la forma registracion si llama al (312) 464-9900 x112**

This camp is offered FREE of charge for kids and teens living with a cancer diagnosis, who have a family member or friend living with a cancer diagnosis or have lost a loved one to cancer. *NOTE: An application needs to be submitted for each child/teen.*

Registration Type *

GCC Teen Camp (July 15-19, 9am-3pm)

Participant's Name *

Participant's Age *

Participant's Home Address *

Parent/Legal Guardian Name *

Parent/Legal Guardian Telephone Number *

Parent/Legal Guardian Email Address *

Emergency Contact Name. If not parent, please indicate relationship to participant. *

Emergency Contact Phone Number *

Participant's Relationship to the Person with Cancer *

Person living with cancer

Family member/friend of someone with cancer

Participant's T-shirt Size (Kids Camp will be youth sizes and Teens Camp will be adult sizes) *

Small

Medium

Large

Please list any allergies/medical conditions including animals (cats/dogs), asthma, diabetes, cancer, bee sting allergy, etc. *

Please list any other special concerns/considerations that you would like Gilda's Club Staff to know about: *

It is required on the first day of camp for the parent or guardian to drop their child off by coming into Gilda’s Club Chicago. At the end of each day, there will be a volunteer waiting outside on Wells St. in front of the building. You, or whoever picks up, will need to give the volunteer your child's name for pick up. *

I will pick up my child from Gilda's Club Chicago at the end of camp each day promptly (3:00pm)

My child will be taken home by an adult at the end of each camp day (3:00pm) and I will provide the adult's name and contact information to Ashley Carrasco, Noogieland Coordinator, prior to the first day of camp.

Please indicate your child's preference for lunch during the week. *

Meat

Vegetarian Option

Other:

Please list any dietary restrictions. *

I understand that the camp agenda will be e-mailed to me and if there any waivers or releases to sign on a paper form I will be responsible for signing them prior to the first day of camp. *

I am checking this box to confirm I have read and agree on the above statement.

Required

To ensure your child "disconnects to reconnect" to the participants, staff, and planned activities, campers are not permitted to possess a cell phone or any other electronic devices for any reason during camp hours (9am-3pm). Any camper violating this policy will have their cell phone/device confiscated until the end of the day. *

I am checking this box to confirm I have read and agree to the above statement.

I, the undersigned hereby grant Gilda's Club Chicago to the right, license, and privilege to use my child's name, likeness, photograph, voice, biography and video in such a manner that Gilda's Club Chicago deems appropriate in order to promote, advertise, and publicize Gilda's Club Chicago and its charitable activities, including on social media, by typing my name as an online signature below. *

By typing my name as online signature below, I am giving permission for my child to attend the Gilda’s Club Chicago’s Kids Camp June 24-28, 2019 or Teens Camp July 15-19, 2019. I am aware my child will be participating in activities both onsite at the Clubhouse and offsite at organizations in Chicago throughout the week. I understand that Sparkle Time is an opportunity for the kids/teens to share their cancer experience with each other at designated times each day of camp. If you have any questions regarding Sparkle Time please contact Noogieland Coordinator, Ashley Carrasco, MSW. I understand that camp takes place at Gilda’s Club Chicago, located at 537 N. Wells Street, Chicago, IL 60654. I understand my child/teen will be riding a school bus to off-site locations including such as: Navy Pier, Wrigley Field & Pump it Up. I understand that we may be walking from Gilda’s Club to nearby local businesses and organizations. I am aware that food options and daily activities are subject to change. By typing my name on this form, I give consent for my child to travel and participate in all activities during the week of Kids Camp, June 24-28, 2019 or Teens Camp, July 15-19, 2019 .I understand my child needs to come prepared for all different types of weather activities and attire for the day's events including the correct shoes for walking and sun protection. Camp t-shirts will be distributed on the first day – they MUST be worn on offsite “community days” to participate. *

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