Other? Type the program name below.
I am the parent/legal guardian of the participant(s) named above, and I hereby give my full consent and approval for my child(ren) to participate in this program at Children’s Cancer Connection, Camp Heart Connection, the Jeff and Deb Hansen Home for Hope or on Children’s Cancer Connection-sponsored field trip/outing. In addition to giving my full consent for my child(ren)’s participation, I do hereby waive, release, and hold harmless Children’s Cancer Connection, its employees, supervisors, volunteers and representatives for any injury that may be suffered by my child(ren) in the normal course of participation in the registered program.
Hand sanitizer and wash stations will be easily available. Masks are not required, but can be provided if a parent would like their child(ren) to still wear one. If the program participant cannot attest to every section of the following screening form below, they will be required to leave the building due to unacceptable practicing of the Children’s Cancer Connection COVID-19 Policy.
I attest that the program participant(s) have not experienced any of the following symptoms of COVID-19 in the past 10 days: fever, chills, cough, congestion or runny nose, fatigue, muscle or body aches, headache, sore throat, new loss of taste or smell, shortness of breath/difficulty breathing, nausea or vomiting, diarrhea.
I attest that the program participant(s) nor anyone in the immediate household tested positive for COVID-19 (Rapid or PCR) within the past 10 days.
The program participant(s) agrees to wash or sanitize hands after using the restroom, sneezing, and coughing.
To ensure a safe and fun environment for all, children are expected to behave in an acceptable manner and use appropriate language at all times. It is important to remember that a child may be asked to leave the program due to unacceptable behavior.
By signing below, I grant permission to Children’s Cancer Connection and its program partner(s) to obtain, store, publish and/or use any photographs, slides, sounds, and/or video recordings made of the program participant(s) named in this form for use on websites, email blasts, social media, advertisements/other promotional pieces, publications, etc. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown.
By signing below, I grant permission to members of the news media authorized by Children’s Cancer Connection and its program partner(s) to obtain, store, publish and/or use any photographs, slides, sounds, and/or video recordings made of the program participant(s) named in this form for use online, on-air, in publications, on social media, etc. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown.
On your own behalf, and as parent or guardian, you acknowledge and agree that there is a possibility of physical injury with your child(ren)’s participation in the program and hereby release, discharge Children’s Cancer Connection, its employees and associated personnel, including the owners of the program facility against any and all claims, liabilities and/or damages as a result of your child(ren)’s participation in the program.
During an event in which a teen participant may drive themselves and/or others, you as the parent/guardian acknowledge that your teen is required to turn in his/her vehicle keys upon arrival and will not be allowed to retrieve them until the program end-time. In the event that the teen needs to leave the facility early, the parent must make prior arrangements with the CCC representative and/or chaperoning adult.
*Notice: For any event that the teen may drive a personal vehicle to, you acknowledge that CCC is not responsible for any accidental claims that may occur while driving to and from the program.
The following people may pick up my child/children from the CCC program. If you are the only authorized person, please provide your own information in the fields below.
*Only those listed below are authorized to pick up the participant(s).*