Camp Angel 2021 Registration

Registration For:*

Camp Angel August 10-12, 9:30 AM - 4:30 PM

Camper's Name*

First Last

Preferred Name*

First

Date of Birth*

Gender*

Which grade will your child be entering in Fall 2022?*

Child's T-Shirt size:*

Address*

Street Address Address Line 2 City State ZIP Code

What category best describes your child?*

American Indian or Alaska Native
Asian, Native Hawaiian, or Pacific Islander
Black or African-American
Hispanic, Latina/o/x, Spanish Origin
Middle Eastern or North African
Non-Hispanic White
Prefer not to Answer
Two or More Races

Your responses to the following questions enable Angel Foundation to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes.

Is this your family's first Angel Foundation activity?*

Yes
No

Is this your child's first time attending Camp Angel?*

Yes
No

How long has your family been utilizing Angel Foundation?*

0-1 year
2-5 years
5 + years

How did you learn about Camp Angel?*

Community Health Worker
Doctor
Friend/Relative
Internet
Nurse
Patient Counselor/Navigator
Social Worker

If you select "Other" please be as specific as possible!

List names of brothers/sisters attending camp

Parent/Guardian and Emergency Contact Information

Guardian #1 (Primary Contact) Name*

First Last

Guardian #1 Email*

Guardian #1 Employer

Guardian #1 Do you have health insurance?

Guardian #1 If so, please provide the name of your insurance provider

Guardian #1 Address (if different than camper)

Street Address Address Line 2 City State ZIP Code

Guardian #1 Cell/Primary Phone Number*

Guardian #2 (Secondary Contact) Name

First Last

Guardian #2 Email

Guardian #2 Employer

Guardian #2 Do you have health insurance?

Guardian #2 If so, please provide the name of your insurance provider

Guardian #2 Address (if different than camper)

Street Address Address Line 2 City State ZIP Code

Guardian #2 Cell/Primary Phone Number

Emergency Contact (Other than Guardian #1/Guardian #2)*

First Last

Please list the Emergency Contact's relationship to the child*

Emergency Contact (Other than Guardian #1/Guardian #2) Phone Number*

Emergency Contact (Other than Guardian #1/Guardian #2) Address

Street Address Address Line 2 City State ZIP Code

Social and Family Information

Who in the family has or has had cancer?*

Please list the type of cancer*

How long has the child's loved one had cancer?*

What is the child's relationship to the family member with cancer?*

How would you describe your child's "coping abilities"? How have they handled their loved one's diagnosis and/or death?*

What has been helpful to him/her as he/she copes/grieves?*

Is there anything else you'd like us to know about your family?

Please list any concerns about home/school behaviors you may have that would be helpful to be aware of before camp.

How does your child function in a group setting? Any tips or ideas that will better help support your child?

Please list any family cultural customs to be taken into consideration.

Health History and Medical Authorization

Please list any dietary restrictions your child may have:

Are there any medical or mental health issues your child has experienced that Angel Foundation should be aware of?*

Yes
No

Please explain in detail:

Please indicate any additional information we should know about your child or their health:

Medical Waiver*

I agree to the Medical Waiver, explained below
I do not agree to the Medical Waiver, explained below

I understand that I must provide the medicine to the staff member designated by Angel Foundation who will thereby be authorized by me and in charge of administration of the medicine according to this schedule. I also consent and authorize Angel Foundation to provide the medications in accordance with the prescription, and to apply sunscreen and insect repellent to my child as needed. I understand that children are prohibited from carrying any medication on their person with the sole exception of asthma inhalants for the child's self-administration if authorized with your signature in the box below.

Please sign in the box below (by typing your name) to confirm your response to the Medical Waiver*

I authorize the staff of Angel Foundation to disclose such conditions to medical professionals in the event medical care is reasonably determined to be necessary*

I agree
I do not agree

Family Photo Release*

I agree to the Family Photo Release, explained below.

Angel Foundation is a nonprofit charitable organization that provides non-medical services to cancer patients and their families. The purpose of this Release is to authorize Angel Foundation to use a photo and/or other information or data about you as described below, for purposes such as marketing and promoting Angel Foundation. 1. Your Information: "Your Information" includes all items and information you provide to Angel Foundation (for example, letters, photos, biographic information, and quotes) as well as things you let Angel Foundation record (for example, your voice, photograph, or video of you and your property), along with your name and biographic information such as the city in which you live. You agree that all rights, including copyright rights, in photographs or other images or recordings taken or made of you by Angel Foundation are owned by Angel Foundation. 2. Rights and Use by Angel Foundation: You agree that Angel Foundation, its successors, assigns, and any entity authorized by Angel Foundation, may use, re-use, edit, modify, publish, display, broadcast, distribute, revise, translate, reformat, create derivative works, copy, and make any commercial or other use of your information, in any electronic, physical, or other medium or format known now or later invented, for any purpose related to Angel Foundation, including but not limited to the marketing of and publicity for Angel Foundation, indefinitely and worldwide, without liability to you or any other person to use. 3. No Payment: You understand that you are not entitled to any royalty or compensation for the rights you grant in this Release. You grant these rights in consideration for the opportunity to have your Information used by Angel Foundation. 4. Release: You agree to release, defend, and hold harmless Angel Foundation, and its agents and employees, from and against any claims and damages for liability arising from or related to the use of your information in any form or format. 5. No Obligation to Use: You agree that Angel Foundation is under no obligation to use any information, nor is Angel Foundation under any obligation to submit materials that incorporate your information to you for your review or approval prior to any use, publication, or distribution of any kind. 6. True Information: To your knowledge, no information or statement that you provide under this Release is false, misleading, or defamatory. 7. Reading and Agreement: You have read this Release before signing, fully understanding the contents, meaning, and impact of this Release, and sign it voluntarily. 8. Age: You are at least 18 years old and have the full right, power, and authority to enter this Release on your own behalf. If you are under 18 years old, a parent or guardian must also sign below.

Please sign in the box below (by typing your name) to confirm your response to the Family Photo Release*

Participant Acknowledgement of Risk, Waiver and Release*

I agree to the Participant Acknowledgement of Risk, Waiver and Release, as described below

The undersigned parent(s) or legal guardian(s) of the child named above state and agree as follows: 1. I have read or have had the opportunity to read about the camp activities and I am aware that these activities in their normal and usual conduct include risks of injury to participants. The nature of camp activities has been fully disclosed to me in brochures, flyers, or announcements relating to the camp and they are expressly made part of this paragraph. I want my child to participate in the camp activities, and other lessons or events at the camp and I expressly assume all the risks inherent, normal and usual to those activities, subject only to the specific limitations on my child's activities listed in "Health History and Medical Authorizations" above. 2. For myself and on behalf of my child, I hereby agree to hold harmless, release and indemnify Angel Foundation's Adult & Family Programs, its staff and volunteers, and Angel Foundation, its officers, agents, employees, affiliates, successors and assigns of and from all claims, demands or damages of any kind or nature (collectively called "claims), whether known or unknown, that I or my child now have or acquire arising from or in any way related to my child's participation in any camp activities (see above), including, additionally, transportation to or from the camp site. This agreement does not apply to claims based upon reckless, intentional, willful or wanton conduct. 3. This agreement is governed by, and is to be constructed in accordance with, the law of the State of Minnesota and is intended to be as broad and inclusive as permitted by law. Any action which is related in any way to this agreement or to claims or rights of parties hereto or of participants in Angel Foundation's Adult & Family Programs activities shall be brought in Hennepin County, Minnesota. 4. If any provision of this agreement is held invalid or unenforceable, the remaining provisions shall continue to be fully effective. 5. No part of this agreement may be amended or modified orally. This agreement supersedes any previous agreement whether written or oral. The undersigned is parent and natural guardian or otherwise designated guardian legally competent to enter this agreement. The undersigned has had sufficient opportunity to read the entire agreement and now signs the same as her/his free and voluntary act. By agreeing to this, I give permission for my child to: -Receive emergency medical care if necessary -Receive over-the-counter medication administered by Camp Angel's staff, as needed. -Participate in therapeutic activities -Attend Camp Angel

True Friends Campground Liability Waiver*

I agree to the information described on the Liability Waiver above

LIABILITY WAIVER I, the undersigned, on my own behalf and/or as the parent/guardian of the minor so named (the “Participant”), hereby agree to the following: COMPLETE WAIVER, RELEASE, AND COVENANT NOT TO SUE. In consideration of True Friends permitting the Participant to be present upon and use the facility commonly known as Camp Eden Wood, located at 6350 Indian Chief Road, Eden Prairie, MN55346 (the “Facility”), and/or participate in the Activities (as defined below) I, on my own behalf and on behalf of Participant if a minor, hereby waive liability on the part of, discharge and agree not to sue or to execute upon any judgment against, and release True Friends, its employees, representatives, directors, instructors, successors, or assigns (collectively, “True Friends”), from any and all liability, loss, injury, death, damages, costs, expenses, including costs and attorneys’ fees, causes of action, and claims of any kind or type, which may have arisen, or may arise, while the Participant is present upon or using the Facility and/or participating in the Activities. ASSUMPTION OF RISK. I am fully aware that there may be risks and hazards associated with being present upon and using the Facility, and I, or the Participant, elect to voluntarily be present upon and use the Facility knowing that there may be risks or hazards. I further understand that while present upon the Facility, I or the Participant may voluntarily participate in activities offered by True Friends, which activities may include, but are not limited to, a challenge course, zip line course, golf cart operation, and waterfront and/or aquatic center use (each an “Activity” and collectively, “Activities”). I acknowledge and agree, on my own behalf and on behalf of the Participant, that the Activities are inherently dangerous and subject the Participant to physical exertion and the possibility of physical illness or injury, ranging from minor to serious or catastrophic injuries and/or death. Risks include, but are not limited to, drowning, falling, injuries resulting from latent or apparent defects or conditions in equipment or property supplied by True Friends, and injuries resulting from Participant’s own physical condition and skill level and Participant’s own acts or omissions. I, on my own behalf and on behalf of the Participant, acknowledge that the Participant is assuming the risk of such illness or injury and agree to bear full responsibility and sole liability for any death, bodily injury, illness, or damage incurred by Participant, even if caused in whole or part by the acts, omissions, errors, or negligence of True Friends, its employees and representatives. I UNDERSTAND THAT THIS IS A COMPLETE RELEASE OF ANY AND ALL POSSIBLE CLAIMS AGAINST TRUE FRIENDS AND THAT I EXPRESSLY RELEASE ANY CLAIMS RELATED TO ANY INJURIES I MAY SUFFER FROM THE NEGLIGENCE OF ANYONE IN CONNECTION WITH THE FACILITY OR ACTIVITIES. I, on my own behalf and on behalf of Participant if a minor, hereby represent and warrant that I have read this General Liability Waiver in its entirety and fully understand its contents. I, on my own behalf and on behalf of Participant, have signed this General Liability Waiver voluntarily and of my own free will.

Please sign in the box below (by typing your name) to confirm your response to the Participant Acknowledgement of Risk, Waiver and Release*

Your Email*

Please provide your email so we may contact you if we have any questions about this form.

Phone

This field is for validation purposes and should be left unchanged.

Camp Angel 2022 Registration Form

Parent/Guardian and Emergency Contact Information

Social and Family Information

Health History and Medical Authorization