Lair of the Bear Epilepsy Family Camp Weekend 2023

Welcome

Date/Time

Thursday, August 17-Sunday, August 20, 2023

Location

Lair of the Golden Bear- Camp Oski

1 Pine Brook Rd

Pinecrest, CA 95364

Cost

We are looking forward to seeing you at our 2023 camp! Since the start of the camp, our goals have always been to provide an incredible experience for kids and families living with epilepsy and to enable every family to attend who wants to go! We are also hoping to enrich the camp programs and expand in 2024.

A fee of $250/person covers the cost to attend camp. However, we don't want any financial burden to prevent families from attending and we offer both partial or full scholarship for any family that requests it. Of course, if you'd like to make additional donations beyond the $250/person fee, that helps us provide the scholarships to those in need.

We welcome donations: https://impact.epilepsynorcal.org/give/77777

*There will be a $500 penalty for no-show or 48 hour cancellation.

Application is to be completed by a parent or guardian. *Please note that if the individual with epilepsy is over 18 years old then please disregard the application being complete by a parent or guardian.

We are so excited to have you and your family join us for a wonderful weekend in beautiful Pinecrest, CA! There is no age limit and we welcome individuals with epilepsy of all ages and their families!

Please enter the information of the individual living with epilepsy. You can enter accompanying siblings on page 3.

If you have any questions please email miriam@epilepsynorcal.org

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.

Scholarship- Financial Assistance

We are looking forward to seeing you at our 2023 camp! Since the start of the camp, our goals have always been to provide an incredible experience for kids and families living with epilepsy and to enable every family to attend who wants to go! We are also hoping to enrich the camo programs and expand in 2024.
A fee of $250/person covers the cost to attend family camp. However, we don't want any financial burden to prevent families from attending and we offer both partial and full scholarship for any family that requests it. *There is a $500 penalty for no-show or 48 hour cancellation.

Scholarship

My family does not need a scholarshipMy family needs a full scholarshipMy family needs a partial scholarship (please specify amount below)

Amount of Partial Scholarship

Page 5 - Authorizations

Authorization

I do herby authorize any medical personnel having records or confidential information regarding my child to disclosure such information to the Epilepsy Foundation of Northern California if deemed necessary.

Electronic Signature: Initial here for electronic signature

Electronic Signature: Enter full legal name

To whom should healthcare bills be sent?

Does your family currently have medical/hospital insurance?

YesNo

Insurance Carrier

Policy#

Group#

Name of policy holder:

Policy holder's birthdate

Relationship to camper:

Lair of the Bear Authorization

This health history is correct and accurately reflects the health status of the camper to which it pertains. The person described has permission to participate in all camp activities except as noted by me and/or the examining physician. I give permission to the physician selected by EFNC / Lair of the Bear to order x-rays, routine test and treatment related to the health of my child for both routine healthcare and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with EFNC / Lair of the Bear staff. I give permission to photocopy this form. In addition, EFNC / Lair of the Bear has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status. In consideration for being allowed to participate in the Camp programs, I agree to assume the risk of such activities and further agree to hold harmless EFNC / Lair of the Bear, its officers, employees and representatives from any and all such claims, suits, losses, or related causes of action for damages. EFNC / Lair of the Bear is not responsible for lost, stolen or damaged personal articles. I also authorize EFNC / Lair of the Bear to have and use photographs, slides or video of me, my child, or my family as may be needed for its public relations programs. I acknowledge that this General Release of Liability and Authorization for Treatment of EFNC / Lair of the Bear is binding on me personally and on my heirs, personal representatives, successors and assigns. This agreement will be enforced in accordance with the law of the State of California.

Parent/Guardian Electronic Signature: Initial here for electronic signature.

Parent/Guardian Electronic Signature: date

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, COVID-19 exposure, 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, Lair of the Bear 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, Lair of the Bear and their officers, directors, volunteers, agents, servants, employees, and affiliates from any and all claims for injuries, including death, damages, COVID-19 exposure, 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, Lair of the Bear 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.

Camper’s Name

Authorized Parent E-Signature:

Date: