Camp Dawn September 12-16, 2019 Application
Camp Dawn is a camping experience for adults with acquired brain injuries. Online applications must have a paper copy medical information form and payment to be considered complete. YOU WILL RECEIVE NOTIFICATION OF ACCEPTANCE TO CAMP BY AUGUST 12, 2019 VIA EMAIL. The provision of direct care in any way is not provided by Camp Dawn. Campers requiring any form of assistance for purpose of self care, safety, mobility or behaviour must be accompanied by their own personal attendant.
Marijuana is not permitted at Camp Dawn unless the individual has a medical marijuana card/prescription. This must be submitted to Camp Dawn and medical marijuana will be locked up with medications. IF ANYONE IS FOUND WITH MARIJUANA AT CAMP WITHOUT A PRESCRIPTION THEY WILL BE ASKED TO LEAVE CAMP. *
Last Name *
Your answer
First Name *
Your answer
Gender *
Address *
Your answer
City *
Your answer
Day phone number *
Your answer
Night phone number
Your answer
Email address *
Your answer
Date of birth *
Your answer
Will the camper be attending with an attendant? *
If bringing an attendant. State attendants name
Your answer
EMERGENCY CONTACT-Name *
Your answer
Emergency Contact-Relationship *
Your answer
Emergency Contact-Phone Number *
Your answer
Emergency Contact -Secondary Phone Number(if applicable)
Your answer
Emergency Contact-Email
Your answer
Alternate Emergency Contact-Name
Your answer
Alternate Emergency Contact-Relationship
Your answer
Alternate Emergency Contact-Phone Number
Your answer
Alternate Emergency Contact-Secondary Phone Number(if applicable)
Your answer
Are you currently receiving rehabilitation support from a community partner. Please checkoff which services you are currently receiving support from.
Please note all meals and snacks are provided by Camp and outside food is not permitted. Furthermore there is a very strict NO NUT policy. Do you have any FOOD allergies or specific dietary requirements? *
Does your dietary considerations include any of the following?
List food allergies and specific dietary considerations to share with the kitchen not listed above.
Your answer
Have you had a fall within the last 30 days? *
Can you provide an example on your mobility ability? *
Please check all devices you are bringing to camp with you *
Required
Camp Dawn can provide the use of bath bench or commode if required please check appropriate device required *
Do you require support with any of the following. Check all that apply *
Required
What t-shirt size preference *
How would you get to camp? *
Is there any further information you would like to share or requests you would like to make to Camp Dawn?
Your answer
Code of conduct- All campers are expected to behave in a manner that is deemed appropriate by Camp Dawn. Campers must make leaders aware of location at all times and all campers must remain on Camp Trillium property for duration of camp. Campers who have driven themselves must hand in keys upon arrival. Behaviour which is deemed unacceptable may consist of but not limited to: Inappropriate aggressive communication, theft, shoving, hitting, touching, or any form of unwelcome physical conduct, sexual comments or gestures, being under the influence of an illegal substance, possession of alcohol or marijuana, possession of any weapon and forming sexual relationships. BREECH OF CODE OF CONDUCT MAY RESULT IN BEING REMOVED FROM CAMP IMMEDIATELY. The camper is responsible for any and all costs associated with removal from camp. Camp Dawn is not responsible for any stolen, misplaced or damaged items during camp. *
Waiver of Responsibility. In consideration of the fee to attend Camp Dawn and of the other good an valuable consideration as set out in the Camp Dawn Application, campers agree to release and forever discharge Camp Dawn Directors, agents, staff and volunteers, including the leaders and attendants jointly and severally from any and all actions, causes of action, negligence, all liability and claims of injuries, accidents and death arising out of the campers experience at Camp Dawn. The campers also agree to indemnify and hold harmless Camp Dawn for any action or claim the camper may make against Camp Dawn relating to their experience at Camp Dawn. CAMPERS SHOULD BE FULLY AWARE OF THE RISKS OF ATTENDING CAMP DAWN INCLUDING INHERENT RISKS WHICH EACH CAMPER IS VOLUNTARILY ASSUMING IN PARTICIPATING IN CAMP AND ACKNOWLEDGES BY AGREEING TO THE TERMS OF THE WAIVER OF RESPONSIBILITY THOSE RISKS INCLUDE BUT ARE NOT LIMITED TO WATER HAZARDS, FIRE HAZARDS AND FALL HAZARDS. Campers shall be fully responsible for their actions and shall accept full responsibility for any and all risks, including all health care risks and complications that may arise while attending Camp Dawn (this includes all travel that is provided by Camp Dawn during the camp experience. It is the responsibility of the camper or, where applicable, the campers attendant or power of attorney, to ensure that the camper fully understands the terms of the Waiver of Responsibility. *
Camp Dawn offers a full variety of recreation activities. The high ropes course is often a favorite of campers. Certified ropes course professionals are hired by Camp Dawn to ensure that we are able to offer this exhilarating experience while ensuring safety for all. If you want to participate in the ropes course you must print off the Adventureworks form and mail in with your medical information form. *
Photographs and or videos may be taken at camp and used for Camp Dawn promotional purposes. Please note-if you check No box below you will not be allowed to be in the group picture. Camp Dawn cannot be responsible for pictures or video taken by campers for personal use *
The cost for attending Camp Dawn is $165 this includes transportation, accommodation, meals, snacks and activities at camp. I will be paying by... *
If using Credit Card-Name on Credit Card
Your answer
Credit Card Number
Your answer
Expiry Date
Your answer
CVS
Your answer
At Camp Dawn, we are committed to protecting your privacy, and will take extra precautions to ensure that the information you provide us will not be shared outside our organization, and only with authorized persons. We will also comply with applicable Canadian Laws when collecting and handling your personal health information. Unfortunately, all technology is susceptible to unlawful intrusions or leaks, regardless of the steps taken, and ours is no different. Because of this, and while we feel that your information is safe with us, we cannot guarantee that your information will be protected from unlawful intrusion. To further secure your information you can mail your Medical Information Form, Payment and Adventureworks ropes course consents to Camp Dawn. If you choose to scan and email these documents we can not ensure your protection and the applicant shall do so at their own risk. *
Your application is NOT considered complete until the date when the medical information form and payment is received. Even if you are currently not taking medications the medical form must be sent in indicating that no medications are being taken at this time. *
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