Registration for the Leucan bereaved couples week-end

Name of the deceased child*

Date of death*

Participants

Name*

First name Last name

Phone number*

Email*

Allergies or food restrictions*

Yes
No

If yes, please specify:*

Name of your spouse*

First name Last name

Allergies or food restrictions*

Yes
No

If yes, please specify:*

Have you moved in the past 6 months? If so, please provide us with your new address so we can update your file

Additionnal information concerning the activity

Have you participated in that week-end before?*

Yes
No

Do you need financial support to cover travel expenses (gas card)?*

Yes
No

Since you will be given a choice of activities to attend to during the week-end, are there any particular subjects you would find important to discuss during your stay?

To take part in this week-end, at least one member of your couple must participate in one of the activities offered throughout the stay*

I confirm that we will be attending one of the activities

Consent

I authorize that photos and videos taken of myself during the activity be used to represent Leucan's mission. I authorize that my name, images, voice and comments be used without limit of territory, media or language to promote Leucan's mission for a period of one year.

Consent*

I agree to respect all instructions and guidelines of the activity organized by Leucan.

Consent*

I acknowledge that my participation in the activity may involve risks, and I hereby assume and freely accept all risks arising from my participation in this activity. I acknowledge and accept that Leucan declines all responsibility for the risks that my participation in the activity may entail and that Leucan cannot be held responsible for any damages of any kind (physical, moral or material) that I may suffer in connection with my participation in this activity. Therefore, I agree to release and hold harmless Leucan, the event organizers, volunteers, sponsors, partners and their respective employees and agents present at this activity from any and all liability for loss, damage or injury to myself as a participant or to my property that may arise or occur in connection with my participation in this activity, and I waive all rights with respect to the foregoing.

Consent*

According to the policy in effect at Leucan, this activity will be alcohol-free.

I, the undersigned, (name of the participant), accept the terms and conditions of this activity.*

First name Last name

Consent for another participant*

Yes
No

Consent

I authorize that photos and videos taken of myself during the activity be used to represent Leucan's mission. I authorize that my name, images, voice and comments be used without limit of territory, media or language to promote Leucan's mission for a period of one year.

Consent*

I agree to respect all instructions and guidelines of the activity organized by Leucan.

Consent*

I acknowledge that my participation in the activity may involve risks, and I hereby assume and freely accept all risks arising from my participation in this activity. I acknowledge and accept that Leucan declines all responsibility for the risks that my participation in the activity may entail and that Leucan cannot be held responsible for any damages of any kind (physical, moral or material) that I may suffer in connection with my participation in this activity. Therefore, I agree to release and hold harmless Leucan, the event organizers, volunteers, sponsors, partners and their respective employees and agents present at this activity from any and all liability for loss, damage or injury to myself as a participant or to my property that may arise or occur in connection with my participation in this activity, and I waive all rights with respect to the foregoing.

I, the undersigned, (name of the participant), accept the terms and conditions of this activity.*

First name Last name

Registration for the Leucan bereaved couples week-end