Camp Christopher Application 2022

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Camp
Camp Christopher
 
Friday, July 8, 2022
Christopher Ranch and Gilroy Gardens

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.

Please enter the information of the child leaving with epilepsy. You can enter accompanying siblings on page 3.


  • 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. 

Page 1 - Camper Living with Epilepsy Contact Information




















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






Guardian Address















Page 3







Page 4 - General Health
















Page 6 - Seizures






















Page 7 - Mental, Emotional, and Social Health 






Page 8 - Authorizations
















Parent/Guardian Consent & Release

PLEASE READ THIS SECTION CAREFULLY BEFORE SIGNING, and be aware that in signing up and participating in this program, and using the facilities and equipment, you will be waiving and releasing all claims for injuries or loss or property damage that you (or your child) might sustain arising in any manner out of this program or the use of the facilities or equipment. This section must be filled out and signed by each participant (or their parent/guardian) or they will not be allowed to participate in this program or use the facilities or equipment.

 

PHOTOGRAPHIC RELEASE – In consideration of the furtherance of the purpose of the Epilepsy Foundation of Northern California and the Epilepsy Foundation of America, I hereby grant permission to the same, their officers, agents, and employees to take photographs or video of me (or my child) and to use and distribute for publication any and all such photographs, video, news releases, and stories for any purpose they may deem proper. In granting such permission, I hereby relinquish any right, title, and interest I may have in such photographs, video, news releases, and stories and grant the Epilepsy Foundation of Northern California and the Epilepsy Foundation of America the right to use these products.

 

ACKNOWLEDGEMENT OF RISK OR INJURY CLAUSE – As a participant in the program, I recognize the risk and acknowledge that there are certain risks of physical injuries, including death, damages, property damage, or loss which I (or my child) may sustain as a result of participating in any and all activities connected with such program or the use of the facilities or equipment.

 

WAIVER OF CLAIM FOR INJURY CLAUSE – I agree to waive and relinquish all claims that I (or my child) may have for injuries or damages, as a result of participating in the program or using the facilities or equipment, against the Epilepsy Foundation of Northern California, the Epilepsy Foundation of America, Christopher Ranch, Gilroy Gardens and their officers, directors, volunteers, agents, servants, employees, and affiliates.

 

RELEASE FROM LIABILITY CLAUSE – I do hereby fully release and discharge the Epilepsy Foundation of Northern California, Christopher Ranch, Gilroy Gardens and their officers, directors, volunteers, agents, servants, employees, and affiliates from any and all claims for injuries, including death, damages, property damage, or loss which may have or which may in the future accrue to me (or my child) on account of participation in the program or use of the facilities or equipment.

 

INDEMNITY AND DEFENSE – I further agree to indemnify and hold harmless and pay defense costs and defend the Epilepsy Foundation of Northern California, the Epilepsy Foundation of America, Christopher Ranch, Gilroy Gardens, and their officers, directors, volunteers, agents, servants, employees, and affiliates, from any and all claims resulting from injuries, including death, damages, property damage, or loss sustained by me (or my child) and arising out of, connected with, or in any way associated with the activities of the program or the use of the facilities or equipment. The undersigned, in case of emergency and in the event the undersigned cannot be reached by telephone, does hereby give permission for medical treatment by a physician or hospital selected by camp staff. Such permission shall include any and all medical treatment, which is necessary or desirable in the absolute discretion of any such physician or hospital. The undersigned recognizes the right of camp staff, in his/her absolute discretion, to terminate a camper’s attendance at any time due to disciplinary or medical actions which might jeopardize the camper’s or other’s health, safety, or well-being at camp. The undersigned further agrees to pick up the camper immediately upon being notified of such termination. If someone other than the undersigned is to pick up the camper at the end of the camp session, such person must present WRITTEN authorization from the undersigned.Click here to enter text