FAMILY REGISTRATION FORM

RETREAT DATES LOCATION APPLICATION DEADLINE

Elim Lodge Aug 28- Sept 1, 2017

Elim Lodge, Buck Horn, Ont.

JUNE 30, 2017

Saskatchewan Jun 28th – Jul 2nd, 2017

Kinasao, Christopher Lake, SK

JUN 1, 2017

Winter Wonderland (TBD) Jan 2018

Camp Galilee, Haley’s Station, Ont.

TBD

ABOUT FAMILY RETREAT

In 2011, Christian Horizons partnered with Elim Lodge (Ontario), Joni and Friends, numerous volunteers, and church and community partners to offer the first Canadian family retreat tailored specifically for families with exceptional needs.

We know that families impacted by disability face unique challenges on a daily basis. Family Retreats are focused on encouraging and equipping your family to face those challenges and to belong to communities in which each family member’s God-given gifts are valued and respected.

Our retreat volunteers will be on hand to assist you and ensure that your family is able to experience everything the retreat has to offer. In addition to the fun and rest, we know there will be many opportunities to connect as a family, develop relationships with other families and be encouraged by the Word of God through teaching, worship, and fellowship.

Family Retreats wouldn’t be possible without the support of many partners and volunteers. If your family needs financial assistance in order to attend the retreat, please consider engaging your local church community for sponsorship. Volunteers are also vital to a great retreat experience. If you know someone who might be interested in serving with us, have them contact familyretreat@christian-horizons.org or contact the Christian Horizons Resource and Leadership Centre at 519-650-6715.

How to Register Read this registration package thoroughly. Select the retreat you

are applying to Apply online or complete all forms, sign, scan and send them by email to:

familyretreat@christian-horizons.org Alternately, complete these forms and send them by mail to:

Christian Horizons – Family Retreat Registrar4278 King Street EastKitchener, Ontario N2P 2G5

FREQUENTLY ASKED QUESTIONS

When do I apply?We recommend registering as early as possible, however we will accept applications up until the dates indicated above. If more applications are received than a retreat has space for we will create a waiting list.

How much does it cost?Each retreat has its own specific costs as listed below:

Retreat Adult (18+)

Teen (13-17) Child (12 and under)

Infant Family Max

Elim Lodge, ON 425 375 200 50Winter Wonderland,

ONTBD TBD TBD TBD

Saskatchewan (A = Wheelchair Accessible)

Retreat Centre Room

260 260 70 FREE

Retreat Centre Suite A (1 available)

275 275 70 FREE

Duplex Private Cabins A (3 available – discounts available for families that share)

275 275 70 FREE

Large Rustic Bunkhouses

250 250 70 FREE

Full Service Trailer Sites (Bring your own camper)

242 242 65 FREE

A nonrefundable deposit is required with your registration and will be applied to your camp costs. The balance of your fees are due at the start of the retreat. Deposits are as follows:

Retreat Deposit RequiredElim Lodge, Ont. $100

Winter Wonderland, Ont.

TBD

Christopher Lake, Saskatchewan

$100

Unfortunately, we cannot provide refunds except for cancellations due to an emergency.

Many families attend with the help of their church, friends or other organizations. Often government funds can be used for respite, education and camping for the family member with a disability. Families who seek support from their church, friends, family and other agencies often discover continuing sources of support and assistance that last far beyond their time at the Family Retreat.

What accommodations/assistance will my family receive?The retreat site is generally accessible, with some rooms being more so than others. We do our best to meet the needs of each family in terms of accommodation, dietary or other needs.

Your family will be assigned a Retreat Volunteer who will offer friendship, support and general assistance. Our volunteers also serve in child and youth programs and may assist in other areas based on their individual skills. Your STM will be with you at each of the meals and program activities.

Each Retreat Volunteer has undergone screening, a background check and training. Several of our Retreat Volunteers have served during previous years and all room in separate accommodations. Personal or medical care are not provided.

If personal or medical care is required for someone in your family, it is your responsibility to make the necessary provisions. Personal Care Attendants are welcome as part of the family unit.

What will my family do at camp?The program is flexible and designed to give your family time together in a camp atmosphere. No activity is mandatory. Children and youth engage in age-appropriate activities while the adults meet together for general sessions and optional workshops. The afternoons will be free for relaxation or participation in optional activities. Evening events are designed for the whole family and may include family games, campfires, or other activities.

FAMILY RETREAT FAMILY REGISTRATION 2017

Contact InformationDate

Mo    Day    Yr      

The Retreat I’m Registering for:      

Primary Contact

     Address

     

City

     Province

  Postal Code     

Email     

Primary Phone(   )     -     

Secondary Phone(   )      -          

Emergency Contact (First and Last name)

     Relationship to you

     Address

     City

     Province

  Postal Code

     Email

     Day Phone

(   )     -     Cell Phone

(   )      -          

FAMILY MEMBERS ATTENDING Please list all persons that will be attending.

ATTENDANTS/CAREGIVERS ACCOMPANYING OUR FAMILY

Name 1 Adult Child/Camper

     Will a personal caregiver be accompanying you?

Yes No

Name 2 Adult Child/Camper

     Name

     Name 3 Adult Child/Camper

     Will this person be staying with you?

Yes No

Name 4 Adult Child/Camper

     Note that the family will be responsible for any additional attendants/caregivers. Their photo consent will be assumed to be the same as your family’s, and if they require an additional room there will be an additional cost. Please follow up with the retreat coordinator at familyretreat@christian-horizons.org with any additional questions.

Name 5 Adult Child/Camper     Name 6 Adult Child/Camper     

FAMILY RETREAT FAMILY REGISTRATION 2017

Agreement I affirm that I have legal custody of the minor children/persons indicated below. Should an emergency occur during the duration of the camp program that I have selected, I give my authorization and consent for the retreat leaders to authorize necessary medical care for this child. Such medical treatment shall be provided upon the advice of and supervision by any physician, surgeon or other medical practitioner licensed to practice in Canada.

I give my consent that photographs, interviews and audio/video recordings during the course of the retreat may be used by Christian Horizons and the host camp location for training, promotion and fundraising. This helps us to promote the Family Retreat opportunity in years to come!

Yes No

I give my consent that information on this registration may be communicated to retreat leaders and Retreat Volunteers for the purpose of being equipped to provide the best care and assistance possible to my family.

Yes No

Would you like your contact information shared with other attendees on a list distributed at the retreat? (Your information will not be shared with any other organization.)

Yes No

I release Christian Horizons, its board, employees, and Retreat Volunteers and the host camp, board, employees and volunteers from all actions, damages, or personal injuries which may occur to me or a member of my family. I understand in the event of a minor injury I, or a member of my family, may receive first aid treatment. I will be informed as soon as possible of any injury or condition of one of my family members and will be responsible thereafter for their care. In the event of an emergency, injury or illness, emergency medical services and I will decide the best course of action. If the retreat leaders are unable to reach me, I authorize them to take whatever action is necessary for the safety and health of my family members.

I understand that I am responsible for personal medical insurance if our family is from out of country.

     SIGNATURE DATE

FAMILY RETREAT FAMILY REGISTRATION 2017

FAMILY RETREAT FAMILY REGISTRATION 2017

Adult #1 Information

Is this your first Family Retreat with us?

Yes No

This person is the same as the primary contact listed above:

Yes (skip contact information) No

First Name     

Last Name     

Date of BirthMo     Day    Yr     

Gender

     

Address (if different than page 1)      

City     

Province  

Postal Code     

Email Address (optional)

     Personal Phone (optional)

(   )      -           Cell Landline

Local church affiliation (if any)     

I would like more information about being connected with a local church Yes No

Health and Support Information

What medical information should we be aware of?      

Please indicate any allergies and food sensitivities and indicate severity.     

Do you have any exceptional needs that we should we be aware of? Please be sure to note any accessibility or accommodation supports required.     

Adult #2 Information

FAMILY RETREAT FAMILY REGISTRATION 2017

Is this your first Family Retreat with us?

Yes No

This person is the same as the primary contact listed above:

Yes (skip contact information) No

First Name     

Last Name     

Date of BirthMo     Day    Yr     

Gender

     

Address (if different than page 1)      

City     

Province  

Postal Code     

Email Address (optional)

     Personal Phone (optional)

(   )      -           Cell Landline

Local church affiliation (if any)     

I would like more information about being connected with a local church Yes No

Health and Support Information

What medical information should we be aware of?      

Please indicate any allergies and food sensitivities and indicate severity.     

Do you have any exceptional needs that we should we be aware of? Please be sure to note any accessibility or accommodation supports required.     

Camper #1 Information

FAMILY RETREAT FAMILY REGISTRATION 2017

Family Name

     First Name

     Gender

     Date of Birth Age

Mo     Day    Yr        

Address (if different)

     City

     Province  

Postal Code

     

Health and Support Information

Please list any medical information we need to be aware of:

     

List all allergies and food restrictions and indicate severity:

     

Doctor’s Name

     Doctor’s Phone

(   )     -     

Do you have any exceptional needs that we should we be aware of?

Please be sure to note any accessibility or accommodation supports required.

     

About You

Favourite activities      

Favourite foods      

Fears or sensitivities      

Important things to know to keep you safe

     

Camper #2 Information

Family Name First Name Gender Date of Birth Age

FAMILY RETREAT FAMILY REGISTRATION 2017

                  Mo     Day    Yr        

Address (if different)

     City

     Province  

Postal Code

     

Health and Support Information

Please list any medical information we need to be aware of:

     

List all allergies and food restrictions and indicate severity:

     

Doctor’s Name

     Doctor’s Phone

(   )     -     

Do you have any exceptional needs that we should we be aware of?

Please be sure to note any accessibility or accommodation supports required.

     

About You

Favourite activities      

Favourite foods      

Fears or sensitivities      

Important things to know to keep you safe

     

Camper #3 Information

Family Name First Name Gender Date of Birth Age

FAMILY RETREAT FAMILY REGISTRATION 2017

                  Mo     Day    Yr        

Address (if different)

     City

     Province  

Postal Code

     

Health and Support Information

Please list any medical information we need to be aware of:

     

List all allergies and food restrictions and indicate severity:

     

Doctor’s Name

     Doctor’s Phone

(   )     -     

Do you have any exceptional needs that we should we be aware of?

Please be sure to note any accessibility or accommodation supports required.

     

About You

Favourite activities      

Favourite foods      

Fears or sensitivities      

Important things to know to keep you safe

     

Camper #4 Information

Family Name First Name Gender Date of Birth Age

FAMILY RETREAT FAMILY REGISTRATION 2017

                  Mo     Day    Yr        

Address (if different)

     City

     Province  

Postal Code

     

Health and Support Information

Please list any medical information we need to be aware of:

     

List all allergies and food restrictions and indicate severity:

     

Doctor’s Name

     Doctor’s Phone

(   )     -     

Do you have any exceptional needs that we should we be aware of?

Please be sure to note any accessibility or accommodation supports required.

     

About You

Favourite activities      

Favourite foods      

Fears or sensitivities      

Important things to know to keep you safe

     

Thank you for filling out this registration! We will be in touch soon.

FAMILY RETREAT PAYMENT (FAMILY)

FAMILY RETREAT FAMILY REGISTRATION 2017Indicate the retreat you are registering for: Elim Lodge, Ontario / Winter Wonderland, Galilee Bible Camp, Ont./ Christopher Lake, Saskatchewan / Other___________________ (indicate one only)This is my: Deposit

Additional payment Tax-deductible donation to scholarship fund

     Name

     Street

My cheque is enclosed (payable to Christian Horizons). Do not send cash

     

Please charge my credit card this amount $       City, Province, Postal Code

MasterCard Visa      Phone

         |    OFFICE USE ONLY

Credit Card Number Expiration Date

Please send me a sponsorship application.

FAMILY RETREAT PAYMENT (FAMILY)Indicate the retreat you are registering for: Elim Lodge, Ontario / Winter Wonderland, Galilee Bible Camp, Ont./ Christopher Lake, Saskatchewan / Other___________________ (indicate one only)This is my: Deposit

Additional payment Tax-deductible donation to scholarship fund

     Name

     Street

My cheque is enclosed (payable to Christian Horizons). Do not send cash

     

Please charge my credit card this amount $       City, Province, Postal Code

MasterCard Visa      Phone

         |    OFFICE USE ONLY

Credit Card Number Expiration Date

Please send me a sponsorship application.