BrainChild 2019 Submission Form
Plugged In Community Centre is giving the gift of learning to children in Sturgeon County, St.Albert, Edmonton and Area through their event BrainChild!

Plugged In Community Centre Organization (Plugged In) is a charitable organization focused on inclusion-based, supportive recreational programming for people regardless of age, ability, or any other potentially segregating factors. PIugged In provides events to create opportunities of inclusion in the community!

BrainChild’s mission is to provide children-in-need, whether disempowered or disengaged, the opportunity to discover a love of learning. This year’s camp theme is sports, mindfulness and academic free thinking.

Our Vision: A community where no child is left behind; where all are nurtured; and where all graduate high school and go on to be productive members of society in adulthood.

What: A free, one-day inclusive camp for kids
When: Saturday, January 26th, 2019 from 9:30 a.m. to 4:30 p.m.
Where: Servus Place in St. Albert
Who: Elementary school-age children

Email address *
Full name of child *
Your answer
Age of the child *
Your answer
Does your child have allergies? *
Is there anything that would prevent your child from fully participating? *
Your answer
Does your child require one-to-one support? *
How did you hear about the event? *
Your answer
What city does the child live in? *
Your answer
If the child is accepted, do they have a way of getting to the event? *
I, the parent or guardian agree to permit the use of photos and or videos of the applicant to appear in the BrainChild 2017 Social Media and website Album? *
Parents or Guardian's Name *
Your answer
Signature of Parent or Guardian , by typing my name I acknowledge this to be my signature. *
Your answer
Contact Information *
Phone Number
Your answer
Contact Information *
Email Address
Your answer
Consent to Participate
Please Read throughly and initial as this is consent to participate in the BrainChild 2018 Event.
Professional Reference, please include Name, phone number, email address and organization. This will be used to confirm the elegibility of the child. *
Your answer
Consent/Waiver *
Plugged In Community Centre Event: BrainChild Waiver of Liability and Indemnity As a condition of entry to the event operated by Plugged In Community Centre Organization (hereinafter "Plugged In") and the use of the equipment, apparatus, and appurtenances therein located, the Undersigned does hereby release, and discharge Plugged In, its shareholders, directors, officers, servants, employs, manufacturers who house events or related equipment, accessories, or products used in conjunction with science to Plugged In, entities from whom Plugged In rents space, subsidiaries or related or affiliated Corporations of Plugged In and the successors and assigns of any of them (hereinafter "RELEASEES") from any and all claims, demands, or causes of action relating to personal injury or property damage howsoever arising and in any way related to my use of Plugged In equipment or attendance at Plugged In premises, whether caused by ordinary negligence, gross negligence, breach of contract, or breach of any statutory or other duty of care and howsoever caused including an alleged breach of the duty of the RELEASEES to protect me from the inherently dangerous activities. I acknowledge and understand that my use of Plugged In equipment or attendance at Plugged In premises is inherently dangerous and I expressly and voluntarily agree to assume all risk and danger of personal injury or damage to property of any kind, including death, dismemberment or paralysis that may result from such use or attendance.I agree to fully indemnify and hold harmless the RELEASEES for and against any loss, liability, damages, costs and expenses suffered or incurred in connection with any claim made by any other person arising from my use of the Plugged In equipment or my attendance at Plugged In premises. Further, I agree that I will not commence legal proceedings or make any claim against Plugged In for damages for personal injury or damage to my property howsoever caused and relating in any way to my attendance at Plugged In premises or my use of Plugged In equipment.This Agreement shall be governed by the laws of the Province of Alberta and I attorn to the jurisdiction of the Courts of Alberta.I acknowledge and agree that all of the terms and conditions of this Waiver of Liability and Indemnity are set out herein in their entirety and there are no other warranties, representations, covenants, or agreements binding Plugged In.I hereby certify that I have carefully read and understand the contents of this Waiver of Liability and Indemnity, and I agree to be bound by its terms. ACKNOWLEDGEMENT OF LEGAL GUARDIAN(Must be completed for participants under the age of 18)IN CONSIDERATION of the minors in this waiver("Minor") being permitted to attend a Plugged In event and to use its equipment and facilities, I, the undersigned parent or legal guardian of the Minor agree on behalf of the Minor that the Waiver of Liability and Indemnity herein contained extends to any claim which may exist or be brought in the name of or on behalf of the Minor, and I agree to indemnify and hold harmless the RELEASEES of and from any and all claims brought by, or on behalf of the Minor, and which are in any way connected with such attendance or use by the Minor. I represent, warrant, and certify that I am the parent or legal guardian of the Minor named herein. I hereby give approval to Minor to attend the premises of Plugged In and participate in the use of its equipment and facilities by the Minor. AUTHORIZATION TO USE IMAGES: Plugged In is hereby granted the right to photograph and/or video record me and/or the listed minors and allowed to use my or their name, voice and appearance in connection with social media and promotional materials. I acknowledge and agree that the rights granted to this release are without compensation of any kind.PRIVACY POLICY: We won't rent, sell or barter your email address to third parties.
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Plugged In Community Centre Organization. Report Abuse - Terms of Service