Last Name*

Mailing Address*

City or Town*

Province*

Postal Code*

Mother's Name

Father's Name

Phone Number 1*

Phone Number 2

Email*

Emergency Contact Person*

This should be someone other than the parents.
Emergency Contact Number*

Relationship to the Camper*

Number of Campers*




 
 
TERMS & CONDITIONS

LIABILITY AND ASSUMPTION OF RISK AGREEMENT 

In consideration of being allowed to participate in any way in the athletic/sports program, related events and Shumka Summer Dance Camps activities, the parent/guardian acknowledges, appreciates, and agrees that:

  1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
  2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
  3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
  4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Shumka Summer Dance Camps and the Ukrainian Shumka Dancers, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”), CONCERNING ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

 

DECLARATION OF COMPLIANCE – COVID-19

The Ukrainian Shumka Dancers and Shumka Summer Dance Camps (from now on referred to as “Organization”) require the disclosure of exposure to illness to safeguard all participants’ health and safety and limit the further outbreak of COVID-19. This Declaration of Compliance will be kept safe, and personal information will not be disclosed unless required by law or with your consent.

 

An individual (or the individual’s parent/guardian, if the individual is younger than 18 years old) who cannot agree to the terms outlined in this document is not permitted to enter the Organization’s facilities or participate in the Organization’s activities, programs, or services.

 

I, the undersigned being the individual named above and the individual’s parent/guardian (if the individual is younger than 18 years old), hereby acknowledge and agree to the terms outlined in this document:

 

  1. The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and COVID-19 is contagious. The Organization has put in place preventative measures to reduce the spread of COVID-19 and requires all individuals (or their parent/guardian, when applicable) to adhere to the compliance standards described in this document.
  2. The individual has not been diagnosed with COVID-19, OR if the individual was diagnosed with COVID-19, the individual was cleared as noncontagious by provincial or local public health authorities more than 14 days prior to the date this Declaration of Compliance was signed.
  3. The individual has not been exposed to a person with a confirmed or suspected case of COVID-19, OR If the individual was exposed to a person with a confirmed or suspected case of COVID-19, the date of exposure was more than 14 days before the date this Declaration of Compliance was signed.
  4. The individual is attending or participating voluntarily and understands the risks associated with COVID-19. On behalf of the individual (or the individual's parent/guardian, the individual - when applicable) agrees to assume those risks, including but not limited to exposure and being infected. 
  5. The individual has not, nor has anyone in the individual’s household, experienced any signs or symptoms of COVID-19 in the last 14 days (including fever, new or worsening cough, fatigue, chills and body aches, sore throat, shortness of breath, respiratory illness, vomiting or diarrhea, loss of taste or smell, or difficulty breathing).
  6. If the individual experiences, or if anyone in the individual’s household experiences, any cold or flu-like symptoms after submitting this Declaration of Compliance, the individual will immediately isolate and not attend any of the Organization’s facilities, activities, programs or services until at least 14 days have passed since those symptoms were last experienced.
  7. The individual has not, nor has any member of the individual’s household, travelled to or had a lay-over in any country outside Canada in the past 14 days. If the individual travels, or if anyone in the individual’s household travels outside Canada after submitting this Declaration of Compliance, the individual will not attend any of the Organization’s facilities, activities, programs or services until at least 14 days have passed since the date of return.
  8. The individual follows recommended guidelines, including but not limited to practicing physical distancing, maintaining separation of three meters from others, adhering to recognized hygiene best practices, and otherwise restricting exposure to COVID-19.
  9. The individual will follow the safety, physical distancing and hygiene protocols of the Organization outlined in the “Back to Camp Plan,” posted on the Shumka website and emailed to all participants before the camp.
  10. This document will remain in effect until the Organization, per the provincial government and provincial health officials' direction, determines that this Declaration of Compliance's acknowledgements are no longer required.
  11. The Organization may remove the individual from the facility or from participation in the activities, programs or services of the Organization at any time and for any reason if the Organization believes, in its sole discretion, that the individual is no longer in compliance with any of the compliance standards described in this document.

 

Media Release
I acknowledge that certain personal information, including my name or my child’s name and photographic or video image, is collected, from time to time, by Shumka Summer Dance Camps, under Ukrainian Shumka Dancers and is required by the Ukrainian Shumka Dancers for its continued and effective operation of Shumka Summer Dance Camps and the Shumka School of Dance. The undersigned hereby irrevocably consents to the use of such personal information in connection with its operations and, including but not restricted to, use in connection with any advertisement, marketing product, broadcast, publication, Donor Perfect database software, Shumka website, Shumka phone application, Facebook page, Twitter page, Instagram page, YouTube page, Dropbox, audio or video recordings, still photographs and artistic renderings without compensation and the undersigned waives the right to inspect or approve any such use in connection therewith.

 

Medical Release

  1. I understand that all information collected will be used to treat or maintain my child's physical or mental health and help prevent disease or injury or promote health. This information is considered to be confidential and will be shared amongst professional health care providers as needed. This information will only be shared with the Camp Director and Camp staff on a need-to-know basis to ensure my child's physical and mental health.
  2. To the best of my knowledge, my child is in good health. I will notify the camp in writing prior to arrival if there is any change in my child’s health before arrival at camp.
  3. In the event of an emergency, I give the camp staff permission to act as guardians in my stead, take my child to the nearest medical facility, complete any required medical documentation, and make arrangements for qualified surgical and medical attention. I understand that I will be notified by the quickest means possible if this authority is exercised.
  4. All prescription and over-the-counter medications must be left with the camp staff while at camp. Prescription medication brought to camp must be in its original packaging and must be labelled with the doctor's name, child's name, dosage, schedule, route and date. If any over-the-counter medications are sent to camp with your child, they must be in the original package and left with the camp staff. 
  5. I agree to reimburse the camp for any prescriptions or medical expenses incurred by my child while at camp.

Supervision

The camp staff supervises campers at all times and in all situations. The Shumka Summer Dance Camps follow the leader/camper ratio standards set by the Alberta Camping Association. Suppose my child does not fully abide by the camp’s rules or does not comply with the camp staff’s reasonable requests. In that case, I will assume full responsibility, including, if necessary, the extra expense of having my child returned home.

 

Transportation

All campers are required to have their transportation to and from camp. Once onsite, campers are transported by the Shumka Summer Dance Camps to any offsite activities (if applicable). I give permission for my child to be transported by Shumka Summer Dance Camps, including transportation required to and from the organized activities. In an emergency, I give my child permission to be transported by the camp staff to the nearest medical facility.

 

Refunds

Much of the planning, including the number of instructors and assistants, snack, food, craft supplies, activity supplies, offsite recreational activity planning, is determined by the number of registrations in the camp. For this reason, refunds will only be issued for medical reasons supported by a doctor’s note or in the case of a family emergency. Shumka Summer Dance Camps evaluate family emergencies on a case-by-case basis. Should COVID-19 protocols result in the 2021 Shumka Summer Dance Camps’ cancellation, all registered families will receive a full refund. 

 

Consent

By clicking YES, I, the Parent or Guardian of the camper or campers named herein, who is/are in my actual custody, acknowledge that I have read and do understand the Waiver and Consent to which this Acknowledgement is attached. This includes: 

 

  1. LIABILITY AND ASSUMPTION OF RISK AGREEMENT
  2. COVID-19 DECLARATION OF COMPLIANCE
  3. MEDIA RELEASE
  4. MEDICAL RELEASE
  5. SUPERVISION CLAUSE
  6. TRANSPORTATION CLAUSE
  7. REFUND CLAUSE

 

I consent and agree to the terms and the binding effect thereof, as they relate to my child or children, and I hereby indemnify the Shumka Summer Dance Camps, Shumka School of Dance, and the Ukrainian Shumka Dancers from and against claims which may arise.

 

I give permission for my child or children listed on this online registration form to participate fully in the selected Shumka Summer Dance Camps. I have read, familiarized myself, and agree with everything in this consent form. 

*


 

After pressing submit, you might need to scroll to the top of the page to view the confirmation.

 

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