Registration Forms are due not later than July 6, 2012
to ensure your spot!
Families on “active treatment” are not required to pay any fees for the Canada’s Wonderland trip. This includes the child, the first and second parent and up to a maximum of six siblings. If only one parent is attending, an alternate parent may attend
(i.e.: adult sibling, grand-parent).
There are limited amount of tickets available for families who are not able to attend on the 20th due to counts, protocols etc. they will be given on a first come first serve basis.
Extra guests will be permitted once all Childcan families have been accommodated. The cost for a guest is $45.00 and also includes a catered luncheon.
Please note attached to this application form is a consent form that is required to be filled out only by participants who are between the age of 16-18 years of age that will not be attending with their parents/guardians and is required to attend this event. If applicable please sign and return with your registration form.
Oncology Child’s Name (First and Last): ______
Child’s Date of Birth: ______
Diagnosis: ______
Date treatment started: ______Date treatment completed: ______
FEES - CHILDCAN FAMILIES
On Treatment _____ No cost
Child off Treatment _____ $20.00
First parent attending trip: ______No Cost/$20.00
(No cost if child is on treatment)
Second parent attending trip: ______No Cost/$20.00
(No cost if child is on treatment)
Please list the name and age of each sibling attending trip. Must be completed in full.
NAME: AGE: FEES
(Please circle the appropriate fee)
______No Cost / $20.00
______No Cost / $20.00
______No Cost / $20.00
______No Cost / $20.00
______No Cost / $20.00
EXTRA GUESTS
I have: guest/s attending at $45.00 each = $
NAME: AGE:
Address: ______
City: ______Postal Code: ______
Phone Number: Home: ______Work: ______
Important!! Please provide current email address as this will be our main form of communication for this trip:
Please indicate mode of transportation below:
We will be riding on the bus from CHWO to Wonderland Yes _____ No _____
Please arrive by 8:00 a.m. at the front of Children’s Hospital, London
We would like to catch the bus in Woodstock Yes _____ No _____
Please arrive by 8:45 a.m. to the designated spot for pick up
We choose to drive to Wonderland Yes _____ No _____
I will be a bus captain for the day Yes _____ No _____
Can we contact you to volunteer at a Childcan event Yes _____ No _____
__ Enclosed is our cheque/money order to help offset the cost of our family’s day at Wonderland
Cheque/Money order payable to Childcan and MUST accompany all forms to ensure a spot.
No post-dated cheques please.
Credit Card Payment Visa or MasterCard
Card#
Expiry Date:
Signature:
Please send cheque/money order and completed participation form and all necessary consents / waivers forms to:
Childcan
Wonderland Day Registration
792 C0mmissioners Rd. West, London, ON N6K 1C2
If you have any questions please do not hesitate to contact Childcan and speak with Shelly Nasution-Moffat at 519-685-3500 or 1-800-966-0631 or
Email:
For those families who are not paying to attend this year’s event you may also fax your forms to Childcan at 519-685-3549.
Credit Card payments will have to be phone into Childcan offices!
Agreement, Release & Indemnity
I/My (individual) We (family application including minor children eighteen years and under) agree that at all times during the Annual Childcan- Canada’s Wonderland Trip our safety remains our sole responsibility. I/We are aware of any risks in participating in this Annual activity and assume all such risk.
IN CONSIDERATION of the acceptance of I/My (individual application- 18 years of age and older) Our(family application including minor children eighteen years and under) to participate in the Annual Childcan – Wonderland Trip I/MY (Individual application – 18 years of age and older) for myself, We (meaning family including minor children eighteen years and under), my heirs, administration and legal representatives RELEASE, WAIVE AND FOREVER DISCHARGE expenses in respect of any death, injury, loss or damage to my person or property (a “loss”) which may be suffered or sustained in any manner as a result of my participation in the Annual Childcan-Canada’s Wonderland Trip and against all liability incurred by any or all of the Parties arising as a result of I/MY, (individual application-18 years of age and older) Our (family application including minor children eighteen years and under) participation in the Annual Childcan-Canada’s Wonderland Trip.
By Signing and Submitting the required application form to attend the Annual Childcan-Canada’s Wonderland Trip, I Acknowledge Having Read, Understood and Agreed to the above.
The terms “Parties” means Childcan, it’s directors, officers, employees and all other associations, bodies, and sponsoring companies and all their respective agents, officials, servants, representatives and successors.
Signature of Participant if over 18 years Date
Parent/Guardian if less than 18 years Date
MINOR CHILD ACTVITY/TRIP CONSENT FORM
Only to be filled out and signed by Parent/Guardian if children are attending the Annual Childcan-Canada’s Wonderland trip unaccompanied and are between the ages of 16-18 years old. Each Child attending needs to have a form filled out.
PARTICIPANTS 16 – 18 years of age
Name of Your Child:
Home Phone: Parent Cell Phone ______
Work Phone:
Home Address: City:
Province: Postal Code:
E-mail: Birth date:
Grade: Sex:
Emergency Contact:
Relationship to Child: Phone:
Does your child (children) have any medical restrictions or allergies?
If yes, please explain and indicate nature and extent
I, parent/guardian) hereby authorize my child,
to participate in the ,
scheduled for , 20 , a program/activity/event which has been organized by Childcan. I further consent to my child using the arranged transportation,
(Bus, private vehicle or public transportation of all forms) as the mode of transporting my child for the above referenced program/activity/event which has also been organized by Childcan.
I hereby further authorize the Childcan officials and/or chaperones in charge of said
program/activity/event to administer or alternatively arrange for the provision of any emergency medical treatment that the Childcan officials and/or chaperones may deem to be necessary for my child’s safety and health during my child’s participation in the program/activity/event.
As lawful consideration for permitting (my child) to participate in this program/activity/event including all related transportation to and from such program/activity/event,
I hereby release and discharge Childcan, its directors, officers, employees and agents from all actions, claims or demands I and my heirs, legal representatives or assigns now have or may hereafter have for any injury or damages resulting from the negligence or other acts, howsoever caused, by Childcan’s directors, officers, employees and agents during my child’s participation in such program/activity/event on and/or away from the Childcan premises, including transportation to and from such program/activity/event.
I have carefully read this Childcan Activity/Field Trip Consent Form and fully understand its contents. I am aware that this is a release of liability and an assumption of risks in regard to my child’s participation and attendance at a Childcan sponsored program/activity/event and sign this Consent Form of my own free will.
This consent and Release from Liability shall remain effective until revoked in writing and delivered to any director, officer, employee or agent of Childcan.
I understand, that in the event my child behaves in a manner deemed unacceptable by a Childcan representative, I will pickup or make arrangements for pickup, of my child at my own expense.
Executed this day of , 20 at , Ontario.
Parent/Guardian Signature
CANADA’S WONDERLAND TRIP INFORMATION SHEET
*Please read and retain this portion of the form for your personal files*
Please remember to bring….
· Suntan lotion and hats
· If taking the bus…Bring a snack, water juice or any special dietary needs for the bus ride there and back
· Kleenex
· Warmer clothing for the evening
· Bathing suits for the water park and towels
· Money for snacks and/or dinner at the park, if desired.
· This trip is on a first come first served basis. Payment must accompany form to hold spot. No post dated cheques please.
· All correspondence for this trip will occur mainly over email (if you have access to email of course). Closer to the date, please check your email regularly.
· Families on active treatment are not required to pay any fees for the Wonderland trip. This includes the child, the first and second parent and up to a maximum of four siblings. A donation to offset the cost of the trip is always greatly appreciated.
· If taking the bus from London, please arrive at CHWO by 8:00 AM. (under the ramp) Your Wonderland tickets and your meal tickets will be waiting for you. A Bus Captain will hand you your package when you board the bus.
· If taking the bus from Woodstock, please arrive at The Quality Inn (580 Bruin Boulevard) by 8:45 A.M. Your Wonderland tickets and your meal tickets will be waiting for you on the bus. A Bus Captain will hand you your package when you board the bus.
· If you are driving to Wonderland your park tickets and meal tickets will be mailed to you. Please ensure that your forms are in by July 6th 2012 at the latest for this purpose.
· The bus departs Wonderland and heads back to Woodstock and London at 7:00 PM sharp!
· There will be one volunteer nurse per bus. All nurses will have a pager/cell phone number. This number will be provided to you the day of the trip for those driving the information will be sent with your tickets.
· We require three Bus Captain’s for the day. Please note on the registration form if you’re interested in volunteering.
· If for any reason a family is unable to attend, a cheque will be issued for their payment as long as 48 hours (minimum) notice is given.
· Special Assistance
Families that require special assistance or have special requirements must contact Paramount Canada’s Wonderland directly and speak with Guest Services at
1-905-832-8131.
· Paramount Canada Wonderland Rentals
Wheelchairs and strollers are available for a one-day rental at the Rental Centre located inside the Front Gate. The rental fee is $10 for a single stroller, $15 for a double stroller or wagon, $12 for a manual wheelchair and $40 for an Electric Convenience Vehicle (ECV). Rentals are provided on a first-come, first-serve basis.
· Adolescents
A child reaching the age of 16 – 18 year’s of age will be allowed to attend without a parent, providing that the parent gives written permission (attach to registration form). The teenager will be allowed to bring one person as an alternate provided that they are also 16 years of age or older and have a signed consent form from pare
· Extra guests will be permitted if there is room available at $45.00/ticket.
· Releasing bus seats: Seats on the bus will be made available to families/friends outside of Childcan once all the registered families that wish to take the bus are assigned a seat. If additional seats are available on the bus, Childcan will release them 2 weeks prior to the event (July 6th).
· A completed consent form is mandatory for any adolescents over 16 years of age (see attached) with all registration forms. Please mail registration and consent form to Childcan at the same time.
· Upon receiving registration forms, all families will receive an email confirmation confirming the number of people attending, mode of transportation chosen and any other additional information required at that time. For those who do not have email you will receive a phone call.
· If you should have any additional questions, please contact Childcan at 519-685-3500 or
· 1-800-966-0631 519- 685-3500 (locally)
OR
· Shelly Nasution-Moffatt by Email:
· Forms not requiring any payment i.e. on treatment families at no cost may also fax your forms to 519-685-3549.
· If paying by Credit Card please ensure that we have all of the correct information on the form!!
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Childcan, 792 Commissioners Rd. West, London, ON N6K 1C2
P.519-685-3500 or 1-800-966-0631 F: 519-685-3549
Registered Charitable (BN#) 11885 1930 RR0001