Child's First Name

Child's Last Name

Child's Date of Birth

Parent's/Guardian's Full Name

Parent's/Guardian's Cell Number

Parent's/Guardian's Email

Address

City

Postal Code

Alternate Emergency Contact

Alternate Emergency Contact Cell Number

Alternate Emergency Contact's Relationship to Child

Preferred Date of Camp Preferred Date of Camp July 24 - 28 August 14 - 18

Does the participant have any allergies or medical condition(s) that we should be aware of? Does the participant have any allergies or medical condition(s) that we should be aware of? Yes No

If yes, please specify. If no, please type in NA.

Does the participant have any mental health concern(s)? Does the participant have any mental health concern(s)? Yes No

If yes, please specify. If no, please type NA.

By clicking on the submit button below, I agree to make full payment of $250+GST for the camp which I can make by credit card when contacted by the office. I also understand and agree that request for refunds must be made in writing at least 7 days before the first date of the camp session for which I have signed up. I can do this by emailing admin@innovatherapy.com. No refunds will be made if a request is not made at least 7 days before the start of camp, once camp has started, or for missed days. In case of a medical or family emergency, I will contact the office directly.

I acknowledge that participation in the activities provided through the camp entails known and unknown risks that could result in physical or emotional injury, illness, disability, death, or damage to the minor child for whom I have enrolled (the “Child”), to property or to third parties. In consideration of Innova Therapy Inc. permitting the Child to engage and participate in the camp, I release, forever discharge, and agree to defend, indemnify, and hold harmless, Innova Therapy Inc., its agents, officers, directors, employees, volunteers, and participants and each of their affiliates (collectively, the “Released Parties”), on behalf of myself, my current or former spouse, and the Child, of and from any and all claims, demands, or causes of action, which are in any way connected with the Child’s participation with the camp activities, equipment or facilities, including any such claims which allege negligent acts or omissions of the Released Parties. Should any Released Party or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I / we agree to indemnify and hold them harmless for all such fees and costs.

I understand that in case of medical emergencies involving the Child, I shall be notified as soon as is reasonably practical, as determined by Innova Therapy Inc., taking into account the specific circumstances. In case I am unreachable, I authorize the camp organizers to call the alternate emergency contact I provided above. I understand that the camp shall not be responsible, and shall be reimbursed, for any medical expenses incurred by them regardless of prior authorization.

I understand and accept that during the course of the camp, the organizers may take pictures, video, or audio recordings (“Media”) for the purposes of advertising and promotion of the camp. Media may be taken of my child. I hereby provide permission for the organizers to use Media that may contain my child's pictures, video, audio recording, or likeness on their website, social media pages, news, bulletins, and ads.

Furthermore, I understand that there is also a risk that the camp’s employees may be negligent in, among other things, monitoring, supervising, and maintaining equipment and facilities. All of the foregoing are risks that I, on behalf of myself and any minors on whose behalf I am signing, specifically accept and by checking this box, I am releasing, indemnifying and forever discharging all of the Released Parties as set forth herein.