Camp Coelho Application

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Welcome

Epilepsy Foundation of Northern California
 

Date/Time
June 23, 2019 – June 28, 2019

Location
CYO Summer Camp
2136 Bohemian Hwy
Occidental CA


Application is to be completed by a parent or guardian. This online process will take about 20 minutes 
You can save your progress and come back to finish later. See option on the top of the page. 
Please be aware when you return you will be redirected to this page, but all the changes you have made will show in the individual pages.


  • EFNC will distribute health information to others only on a need-to-know basis and will otherwise endeavor to keep the information confidential.

     

    The EFNC has put in place the basis and means for appropriately protecting the data, including e-data, that camp creates, receives, transmits, or retains. This is not simply health information, but includes other camper/family personal information, participant agreements, payment and enrollment information. 

IF YOUR CHILD HAS ATTENDED CAMP IN 2018 CONTACT US AT CAMP@EPILEPSYNORCAL.ORG 
WE WILL REPOPULATE THE APPLICATION WITH 2018 INFO

Page 1 - Camper Contact Information



















This will be the e-mail used to contact you regarding your child's application. 
Camper's Address






Billing Address

















Scholarship - Financial Assistance Application

We ask families to pay what they can afford. All information must be included to be considered for a scholarship. 




Page 2 - Camper Personal Information










Page 3 - General Health


























Page 4 - Immunizations & Medications

Starred (**) immunizations must be current (please list date given):







Page 5 - Medication








Page 6 - Seizures






















Page 7 - Mental, Emotional, and Social Health 























Page 8 - Authorizations
















Publicity and Photo Release Form

I hereby grant to the Epilepsy Foundation of Northern California the absolute and irrevocable right and unrestricted permission to use my or my family’s name, likeness, image, voice, and/or appearance as such may be embodied in any photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the Foundation or its partners. I agree that the Foundation has complete ownership of such material and can use said material for any purpose consistent with the Foundation’s mission. These uses include, but are not limited to, videos, publications, advertisements, news releases, Web sites, and any promotional or educational materials in any medium. I acknowledge that I will not receive any compensation for the use of such images, video, likeness, etc. 

I hereby release and discharge the Foundation, and its agents, representatives and assignees from any and all claims and demands arising out of or in connection with the use of my name, likeness, image, voice and/or appearance, including any and all claims for invasion of privacy, right of publicity, misappropriation or misuse of 
image, and/or defamation. 

I represent that I am over the age of eighteen (18) years and that I have read the foregoing and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns. 
This agreement is being made and entered into under the laws of the State of California and shall be governed and interpreted in accordance with the laws of said state. This agreement embodies the entire agreement of the parties (subject and photographer). No modification of this agreement shall be of any effect unless it is made in writing and signed by all of the parties to the agreement. 




Page 9 - Additional Documents

**IMPORTANT: Your application has *NOT* been submitted yet. Please go through the checklist on this page and scroll all the way to the bottom to finalize and submit your application. We will have no records of the application until it is submitted via 'Submit" button on the bottom of this page.** 
Physician Report
Please download the Physician Report form at 
which is to be completed and signed by a licensed physician and sent or uploaded below to the Epilepsy Foundation of Northern California. 
This examination must be performed within 5 months of camp. 

Release Forms, Communications Policy & Checklist 

Please download and complete the CYO Release Form at 


Please download and complete the EFNC Publicity and Photo Release Form at