Community Program Registration Form

Please select which program you are registering for.*
  • Camp Kerry Community Choir: North Shore
  • Camp Kerry Community Choir: New Westminster
  • Circles of Strength: New Westminster
  • Circles of Strength: North Vancouver

Primary Registrant

Date of Birth: dd/mm/yyyy
Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*

If you also intend to register your child(ren) then you may do so here. This will save you time and alleviate the need to complete additional forms. If this is applicable to you then please provide us with the following information for any additional paricipants that you wish to register in the box below:

  1. First and Last Name
  2. Date of Birth in the following format: dd/mm/yyyy
  3. Gender
  4. Any allergies/medical concerns that we should be aware of
  5. Relation of loved one(s) who has passed to your child(ren)
Additional Registrant's Information

Loved One(s) Remembered

Honoring our loved ones who have passed connects us with one another and provides us with opportunities to heal. Please tell us who you are remembering.

Loved one's Name
Date of Loss
If you are remembering more than one person, please tell us their first and last name, how they're related to you, date of loss, and cause of death.

Emergency Contact Information

Emergency Contact: Name
Emergency Contact: Number
Emergency Contact: Cell Number

In the case of an emergency I agree to give permission for the nurse and/or qualified personal to administer prescriptions, over-the-counter medications, first aid and/or access to medical treatment, if needed.

Health Information

We want our programs to be accessible and comfortable for all our participants. We also want to be able to respond appropriately in the event of an emergency. Do you use any assistive devices that you want us to be aware of?
  • Asthma Inhaler
  • Cane/Walker
  • EpiPen
  • Hearing Aids
  • Insulin Dependent
  • Prosthetic Device
  • Wheelchair/Scooter
If there are any restricted activities that you would like us to know about then please tell us here.
Allergies/Sensitivities
  • Peanut Allergy
  • Other Food Allergy
Describe any additional information about your health that you would like us to know so that we can accomodate you better.

Photo & Video Permission

 

In order to capture memories and document activities we frequently arrange for pictures and videos to be taken of participants in our programs and at events our organization is associated with.

These images/videos are generally utilized for a variety of purposes including; Promotion of the Camp Kerry Society, Educational Purposes, Project Evaluations, and most often they are shared amongst other fellow participants. These photographs and videos may also be used for external public viewing on our website and/or other platforms of social media, in promotional materials, and by news media for Camp Kerry Society related stories.

If you consent to have photo/video images of yourself used as noted above then please select the "Permission Granted" option below. If for any reason you don't want us to use your images/photos then please select "Permission not granted".

Acknowledgement of Risk & Release of Liability

In consideration for my own, and/or my child/children’s participation at programs and/or events of the Camp Kerry Society, I hereby release, hold harmless and indemnify the Camp Kerry Society, its members, officers, directors, employees, volunteers and independent contractors, from all liability, claim, causes of action of any kind whatsoever in respect to all personal injuries, loss of life or property losses which our daughter/son/ward/myself, may suffer arising out of the activities organized by or associated with the Camp Kerry Society. That I do hereby acknowledge and agree that the adventure activities such as those listed may be dangerous and expose our daughter/son/ward/self to risks and hazards: swimming, hiking, climbing walls, ropes courses, canoeing, kayaking, ball sports, campfires, horseback riding, fishing and that other activities designed to address grief and loss such as; sharing circles, memory services, and memorial activities, may elicit emotional discomfort. That I freely and voluntarily assume all of the aforesaid risks and hazards for my daughter/son/ward/self. That I have carefully read this release, waiver, and assumption of risk agreement, that I fully understand same, and that I am freely and voluntarily executing same. That I clearly understand that by agreeing to and accepting this release, I will be forever prevented from suing or otherwise claiming against the Camp Kerry Society, its members, officers, directors, employees, volunteers, or independent contractors with respect to any mater arising from these activities.

Registration Fee

 

The registration fee represents a very small percentage of the actual amount that the Camp Kerry Society must fundraise in order to operate these programs. 

 

For those in need of financial assistance, we are more than happy to talk with you about a fee-reduction and about creating a payment schedule in line with your comfort level. This simply involves a short, confidential phone call to our office - 604-553-4663 - to discuss your concerns with our Administrative Coordinator. We want to give you our absolute assurance that no one will ever be turned away from programs of the Camp Kerry Society due to an inability to pay.

 

REFUND POLICY
The Camp Kerry Society requires advance notice of cancellation to provide the following refunds:

  • 100% refund if you must cancel due to medical/family emergency issues
  • 100% refund if you cancel 14 days or more prior to the first session
  • 50% refund if you cancel 6 to 13 days prior to the first session
  • No refunds if you cancel 5 days or less prior to the first session

Please make your selection from one of the following options. Please note:

 

*We accept Visa-Debit Cards as well as most credit cards

 

*Paying by cheque? Call our office to complete your registration.

 

*Tax Receipts cannot be issued for registration fees.

 

Donation Amount*
  • Circles of Strength: Single Session ($15)
  • Circles of Strength: 2017 Series ($80)
  • Community Choir: Senior/Student ($70)
  • Community Choir: Adult ($95)
  • Other $

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code

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