Cabin Leader Application

First Name *

Last Name

Phone *Cabin Leader

Email Address *Cabin Leader

Date of Birth *

Cabin Leader

Age during camp *Cabin Leader

Select *Cabin Leader

How did you hear about Camp Courage? *Cabin Leader

Have you attended Camp Courage before? *Cabin Leader

Emergency Contacts

First Name *Emergency Contact 1

Last NameEmergency Contact 1

Relationship *Emergency Contact 1

Phone *Emergency Contact 1

First Name *Emergency Contact 2

Last NameEmergency Contact 2

Relationship *Emergency Contact 2

Phone *Emergency Contact 2

Health History / Medications

Select *Cabin Leader

If yes, please answer the following questions: What was the cancer diagnosis? How old were you when you were diagnosed? Are you currently on treatment? If you are in remission, how many years?Cabin Leader

Select *Cabin Leader

If yes, please list the allergies and associated allergic reaction(s).Cabin Leader

Select *Cabin Leader

If yes, please provide the date and description of the most incident.Cabin Leader

Select *Cabin Leader

If yes, please explain.

Select *Cabin Leader

If yes, please provide the name of the drug, dose amount, frequency, and reason for taking.

Do you currently have any medical conditions, activity restrictions, physical or mental disorders, or any other conditions that would require special accommodations? *

Free Response Questions

Why do you want to be a cabin leader and what do you hope to gain from the program? *No more than one paragraph. (3-5 sentences)

Camp Courage is a camp for kids dealing with the challenges of pediatric cancer. Do you have a personal connection to this cause? *No more than one paragraph. (3-5 sentences)

What skills do you have that will help you be successful as a cabin leader? *No more than one paragraph. (3-5 sentences)

Give an example of a situation where you have taken a leadership role, describe the situation and the outcome. *No more than one paragraph. (3-5 sentences)

Required:

In order for your application to be considered complete, all Cabin Leader Applicants will be required to submit 1-2 references. Please have your references visit camp-courage.org/reference to complete the reference form. Your current application can still be submitted below after providing your signature.

Signature

I hereby confirm that all information provided in this application is the truth to the best of my knowledge. (Cabin Leader)

Permission for Media (Photos & Video)Permission for photographs and interviews of campers under 18 years of age can be granted to the media ONLY with parent/guardian approval. These photographs, written interview quotes and verbal interview statements will appear in information about Camp Courage programs and people. I understand that Camp Courage shall not be liable for royalties, commissions, or payments of any nature to me or my child in connection with such filming, photographing, and/or interviewing. Camp Courage assumes no liability of any nature in connection with such filming and/or interviewing. I hereby give permission to Camp Courage to be filmed/photographed and interviewed by the media.

Select *Do you give permission to Camp Courage to allow you to be filmed/photographed and interviewed by the media?

Signature *

Please sign if you agree to give Permission for Media (Photos & Videos)

Please Fill out all of the information requested. By writing your name below you agree to the following:o I certify that all information on this application is true and correct. o I have informed you of any special needs that will require attention during my stay at camp. o I will review the rules and guidelines of expected behavior at Camp Courage before my time at camp. o Because there is no regularly scheduled transportation, if for any reason it is determined by the Camp Courage staff that I must leave before the end of the session, I agree to be responsible for my own transportation from Camp within 12 hours.

Date *

Signature *

Cabin Leader

Waiver and Release of LiabilityIn consideration of being allowed to participate in Camp Courage (“Activity”), to the extent permitted by law I hereby forever discharge, release, and hold harmless School District No. 1, in the City and County of Denver and State of Colorado (the “District”), and its employees, officers, directors, agents, representatives, and authorized volunteers (collectively, the “Releasees”) from any and all liability, claims, demands, actions, and causes of action arising from or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in the Activity. I am fully aware of the potential risks and hazards and I hereby elect to voluntarily participate in the Activity. I knowingly and freely assume all potential risks, known and unknown, including those arising from the negligence of the Releasees. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, further agree to indemnify and hold harmless the Releasees from any loss, liability, damage or costs, including court costs and attorneys’ fees, that Releasees may incur due to my participating in the Activity, including those caused by the negligence of the Releasees or otherwise. I have read this Waiver and Release of Liability (“Agreement”) and fully understand its terms. I also understand that I have given up substantial rights by signing it and sign it freely and voluntarily without any inducement. I am at least eighteen (18) years of age and fully competent to sign this Agreement.

Date *

Signature *

Participant

WAIVER, RELEASE AND ASSUMPTION OF RISK BALARAT Challenge Elements/DENVER PUBLIC SCHOOLSThe Denver Public Schools’ Balarat Challenge Elements are part of an experiential education program that offers groups and individuals the opportunity to engage in personal development and team building activities. A challenge course, commonly known as a ropes course, is composed of wooden frameworks, cables, and belay systems that are used for the facilitation of the aforementioned activities. As a participant at the Balarat Challenge Elements (the Course), I agree as follows: My participation should be within my own physical, emotional, and other limitations. The Course consists of physically demanding elements that involve bending, twisting, lifting, swinging, balancing, and climbing to heights of approximately 40 feet. The Course will involve contact with others and harnesses that may induce pressure on my hips, back, chest and stomach. The physical exertion can be intense, involving increased heart and breathing rates. There are unforeseen risks inherent in these physically demanding activities. Additionally, the Course is outdoors, thus may be exposing me to extreme heat/cold, sunlight, dangerous weather, dehydration, bugs, spiders, ticks and other potentially harmful factors. I acknowledge that when participating in these activities there is a possibility of physical injury. I acknowledge that I can elect not to participate in part or all of the activities. I agree to consult with my personal physician before participating or I acknowledge that I have voluntarily declined to do so. If I choose to participate in the Course activities, I do so voluntarily and at my own risk. I personally assume all risks associated with being a participant on the Course, whether or not that risk is specifically noted herein. I acknowledge and assume all medical expenses that may arise related to my participation and acknowledge that no medical insurance is being provided by or through the “releases” outlined below. I waive, release and discharge for myself and my heirs, executors, administrators, legal representatives, assigns and successors, Denver Public Schools and all their agents, officers and employees (collectively referred to as “releasees”) from all claims, demands, and causes of action of any kind, including claims for negligence which may arise from or be related to my participation at the Course. As a participant, I acknowledge my responsibility for my, and others, safety and will follow the safety criteria established by DPS/Balarat staff. Failure to do so may result in restrictions and/or my dismissal from the Course. My signature below binds my heirs, executors, administrators, legal representatives, assigns, successors and me. By signing below I agree that I have carefully read and assent to all of the terms stated above. If I am signing as a parent/guardian/legal representative, I agree on the minor’s behalf.

Date *

Signature *

Participant

Emergency Contacts

Health History / Medications

Free Response Questions

Required:

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