This form must be filled out by all CHWC participants (Youth, Adults, Clergy, Etc.)
Participant Name *
AS IT APPEARS ON YOUR PASSPORT
Passport Number * Parish / Group * St Mary of the Presentation Blessed Sacrament Catholic Church St. John the Baptist St. Ambrose & St. Peter's Church Have you attended CHWC before? * How many years? * Shirt Size * Small Medium Large XL 2XL 3XL
*NOTE: We cannot guarantee what sizes will be available at camp but will do our best to fulfill your request.
Age Category (at the time of camp) * Youth (under 18) Young Adult (18-20) Adult (21 and older) Are you a member of clergy or professed religious? * Please Specify * Priest Deacon Ordained Religious Religious Brother/Sister (not ordained) Seminarian Grade entering in the fall of 2023 * 8th 9th 10th 11th 12th Cell Phone * Email * Other Jobs at Camp
*Must be at least 21 years old.
CATHOLIC HEART WORKCAMP
MEDICAL INFORMATION & RELEASE OF ALL CLAIMS
Participant Date of Birth * Emergency Contact, Relationship to Participant * Emergency Contact, Phone Number * Health Status: Please list any health problems you may have
Example: asthma, allergies, back trouble, diabetes, seizures, mental disorders or illnesses
Please list all medications taken routinely (over the counter and prescription)
Please include the name, dosage and reason for taking it. Please also bring enough medication to last the entire time at camp and keep all medications in the original bottle.
Physician Name * Physician Phone Number * Date of your last Tetanus Booster
Preferred but not required.
All participants must have health insurance in order to attend CHWC. Health Insurance: Provider * Health Insurance: Policy Number * Health Insurance: Group Number * RELEASE OF ALL CLAIMS *
I have read, understand, and agree to the RELEASE OF ALL CLAIMS outlined below.
In consideration for being accepted by Catholic HEART Workcamp L.L.C. (CHWC), a Florida limited liability company, I, being 18 years of age or older, do for myself and, if applicable, for and on behalf of my child-participant (if said child is not 18 years of age or older) do hereby release, forever discharge and agree to forever hold harmless Catholic HEART Workcamp and its managers, members, directors, officers, employees, and agents thereof, from any and all liability, claims, demands for personal injury, sickness, death, as well as property damage and expenses of any nature whatsoever, including, but not limited to, bacterial and viral diseases such as, but not limited to COVID-19 and any other infectious diseases, which may be incurred by the undersigned or the child participant resulting from participation in the above-described workcamp (including, but not limited to, travel between the child's home and the camp, free day activities, excursions from the camp, and anytime spent at the camp). Furthermore, I (and on behalf of my child-participant if under the age of 18 years), hereby assume all risk of personal injury, sickness, death, damage, and expenses as a result of participation as above set forth. Moreover, Catholic Heart Workcamp (CHWC) is not responsible for any injuries sustained by individuals or groups while swimming. Swimming is an activity that carries inherent risks, and participants assume all responsibility for their own safety while engaging in this activity. CHWC does not provide supervision or instruction for swimming activities, and it is the responsibility of each participant to take appropriate precautions and to swim at their own risk. CHWC will not be held liable for any injuries or damages that may occur as a result of swimming. Additionally, authorization and permission are hereby given to CHWC to furnish any necessary transportation, food, and lodging for and to assign work projects to this participant. The undersigned, on behalf of themselves and, if applicable, their child participant, further agree to hold harmless and indemnify Catholic HEART Workcamp and associated social agencies and daycare centers and their directors, officers, employees, and agents, for any loss, claim, liability, damage, including property damage or injury whatsoever incurred by child-participant as a result of the negligent, willful or intentional acts of said participant, including reasonable attorney’s fees and other expenses incurred attendant thereto.
I, as an adult, 18 years of age or older, if I am unable to speak for myself, hereby give my permission to CHWC to transport me to a doctor or hospital and hereby authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and I assume the responsibility of all medical bills and transportation costs. I also authorize the release of medical records to an attending physician in case of a need for medical treatment. Further, I hereby assume and indemnify Catholic HEART Workcamp, L.L.C. for all transportation or medical costs. I am aware of no physical, mental, or emotional problems, which would limit my participation in or work performance at CHWC. I am fully aware of the nature of the work to be undertaken during the Catholic HEART Workcamp.
If applicable, I, as the parent or legal guardian of this participant under the age of 18 years of age, hereby grant my permission for him (her) to participate fully in said workcamp, and hereby give my permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and I assume the responsibility of all medical bills. I give permission for my child to be transported in privately owned vehicles or in public transportation and for the release of medical records to an attending physician in case of a need for medical treatment. Further, should it be necessary for the participant to return home due to disciplinary action, for medical reasons, or otherwise, I hereby assume and indemnify Catholic HEART Workcamp, L.L.C. for all transportation costs. I am aware of no physical, mental, or emotional problems, which would limit participation in or work performance during the workcamp. I am fully aware of the nature of the work to be undertaken during the Catholic HEART Workcamp.
The Catholic HEART Workcamp will employ reputable staff members and take reasonable precautions to safeguard the CHWC participants during the week of the workcamp. However, neither the Catholic HEART Workcamp L.L.C., associated social agencies, nor the school acting as “home base” will be liable for loss or damage to property of participants prior to, during, or following the workcamp due to theft, fire, accident or any other cause beyond its control.
CATHOLIC HEART WORKCAMP
MEDIA WAIVER, CODE OF BEHAVIOR & ALCOHOL POLICY ACKNOWLEDGMENT
MEDIA WAIVER *
I hereby authorize and give my full consent to Catholic HEART Workcamp L.L.C. to copyright and or publish any and all photographs, video or audio in which I/my child will appear in while attending Catholic HEART Workcamp. I further agree that Catholic HEART Workcamp may transfer these photographs, video or audio for use on the Catholic HEART Workcamp website and all promotional material.
CODE OF BEHAVIOR *
I have read, understand and agree to follow the CODE OF BEHAVIOR outlined below and understand that if violated, CHWC has the right to send a camper home at their expense. I further agree that Catholic Heart Workcamp, in its sole discretion, will determine if any of the rules below were violated.
As a CHWC participant I will:
• Represent the Catholic Christian community through my language, dress and behavior.
• Respect the rights and property of others.
• Respect CHWC staff and adult leaders, even if these leaders are not from my group.
• Remove my hat, refrain from eating, drinking, and private discussions during Mass.
• Participate in all planned activities, group sessions and work projects.
• Read over the school, safety and worksite requirements in the youth or adult pre-trip planning booklet and will abide by them.
• Read over the rules for cell phone usage in the pre-trip planning booklet and will abide by them.
• Respect the privacy of my fellow campers and not go into any other sleeping quarters (guys or girls) that are not assigned to my group.
• Adhere to the stated curfew (10:30pm prepare for bed and 11:00pm lights out).
• Be responsible for assisting our group with snacks and help keep snack area clean.
• Not possess any alcohol, marijuana, non-prescription drugs, electronic cigarettes, JUUL devices, fireworks, weapons or knives (including pocket knives).
• Not leave the school grounds without adult supervision.
• Build new relationships with my team, resident, agency leaders, others in the community I encounter during this service week.
• Read over the policy on Sexual Harassment / Misconduct.
• Refrain from inappropriate touching and verbal harassment.
• Not engage in any form of sexual activities or sexual harassment.
• Not take part in any form of bullying which includes (one or more students seeking to have power over another student through the use of verbal, physical or emotional harassment, intimidation or isolation).
• Encourage other group members to live by these rules.
*NOTE: If you are filling this out on your child’s behalf, please ensure they have reviewed the CODE OF BEHAVIOR above. ALCOHOL POLICY ACKNOWLEDGMENT *
In the spirit of fully embracing a different culture, occasionally there may be times when wine is available at meals provided by CHWC.
As legal drinking ages in Italy differ than in the U.S, we ask those under the age of 21 opting to consume alcohol during these meals have their Parent/Legal Guardian grant permission for the above participant to responsibly consume alcohol during meals provided by CHWC.