NOTE: Ecosource Mississauga does not accept paper waivers, please submit electronically.

Ecosource Summer Camp Form

Thank you for your interest in our summer camp! In order for your child(ren) to participate in the summer camp, please complete the following form.

Full Name of Child(ren)

Parent/Guardian Full Name

Parent/Guardian Email Address

Parent/Guardian Phone Number

YES! Sign me up to receive monthly updates on Ecosource events and volunteer opportunities

Media Release

1. I understand that photographs, videos and/or evaluation may be taken of my child(ren) and/or of myself and may be used in the promotion of Ecosource. They may be published or used for any application in newspapers, magazines, film, television commercials, posters, slide presentations or otherwise displayed to the public or used for educational, fundraising, information or training purposes.

2. I understand that I will not receive any compensation for photographs or videos taken of my child(ren) and/or myself during Ecosource activities.

Please select one of the following options:

YES, I give consent for my child(ren) and myself to be photographed, videotaped, and to participate in evaluation for the program.

NO, I do not give consent for my child(ren) and myself to be photographed, videotaped, and to participate in evaluation for the program.

Permission to Leave Property

During the camp week, Ecosource staff will be taking campers off site to an urban agriculture space as well as local parks and trails.

During the camp week, a school bus will be taking campers and staff to our Iceland Teaching Garden, located at 705 Matheson Boulevard East in Mississauga (approximately a 10-minute drive).

In addition, at various points in the week, campers may walk to visit the neighbouring park and paved trails located within 500 metres of the Ecosource office.

Off-site excursions are part of this camp program. If you have questions about this, please contact us at camp@ecosource.ca. Please check the box below to grant staff permission to leave Ecosource property with your child(ren).

I give my permission for my child(ren) to leave the property at 5070 Fairwind Drive, Mississauga ON L5R 2N4, to participate in off-site excursions by walking or school bus.

Pick-up Authorization

Please list below the individuals who are authorized to pick up the child(ren) from camp.

Include full names, phone numbers, and relationship with child(ren)

Informed Consent & Assumption of the Risk and Waiver of Liability

Please read the following carefully.

1. I hereby willingly consent to release Ecosource from all liabilities and waive all claims and demands arising from personal injuries I (or the participant/volunteer if under 18 years of age) may incur while participating/volunteering with Ecosource.

2. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I (or the participant/volunteer if under 18 years of age) may be exposed to or infected by COVID-19 by participating in Ecosource’s programs and that such exposure or infection may result in personal injury, illness, permanent disability, and death.

3. I voluntarily agree to assume all of the COVID-19 risks and accept full responsibility for any injury to me (or the participant/volunteer if under 18 years of age), while participating in Ecosource programs including any claims, losses, personal injury, disability, death and any other health related COVID-19 risks. I agree to hold harmless, indemnify, defend and waive any liability against Ecosource from any direct or indirect damages, suits or claims including legal expenses sustained as a result of or in relation to any matters under this agreement or in consequence of any breach of any representation or obligation made herein.

4. I understand and agree that Ecosource may share my personal information (including my name and contact information) with other agencies, including Peel Public Health, for the express purpose to manage the spread of COVID-19. If it is necessary to disclose my personal information, I understand that I will be contacted in advance and provided the reason for disclosure, unless this is prohibited by law or regulation as determined by a public body.

5. Ecosource is committed to fostering a safe, inclusive, and welcoming environment through our programming. All participants/volunteers are expected to uphold our value of inclusivity and not engage in behaviours or actions that are discriminatory or may be perceived as discriminatory by others. Violation of this policy may result in discipline including removal from the program at the discretion of Ecosource.

I am the parent or legal guardian of the child(ren) named above. I have read the Informed Consent & Assumption of the Risk and Waiver of Liability and I understand the legal consequences of signing this document. I assume all risks of my child(ren)’s participation in Ecosource’s programs and agree to waive any claims relating to their participation against Ecosource and their respective employees.

Click to Sign

Signature of Parent/Guardian

Sun May 5, 2024