Connect Form

The information requested is necessary to better understand your needs. Please be assured that all information submitted will be kept confidential. Your health information is private. Please note that incomplete referral forms will delay client follow up.

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DISCLAIMER:  Cancer Care Services disclaims any and all liability for any unauthorized or inappropriate use of equipment furnished, information provided, or participation in programs by Cancer Care Services or its agents that may result in physical injury or bodily harm.

WAIVER:  It is expressly agreed and understood that all use of Cancer Care Services, programs, instructions, and equipment shall be undertaken by the undersigned at his/her sole risk.  Cancer Care Services shall not be liable for any injuries or any damage whatsoever to the undersigned for any injury or damage to any property of the undersigned.  Also, Cancer Care Services shall not be subject to any claim, demand, injury, or damages whatsoever, including, without limitation, those damages resulting from acts of active or passive negligence on the part of Cancer Care Services, its officers or agents, or anyone using Cancer Care Services facility or equipment or other program locations.  The undersigned, for himself/herself and on behalf of his/her executors, administrators, heirs, personal representatives, successors and assigns, does hereby expressly forever release and discharge Cancer Care Services, its owners, officers, associates, agents, instructors, assignees and successors from all claims, demands, injuries, damages, actions, or causes of action in any manner related to the use of Cancer Care Services facility or equipment, premises or parking lot, other program locations, any information provided, and participation in any programs.

I understand that participation in Cancer Care Services programs is voluntary and no Cancer Care Services employee, board of director or officer convinced, coerced or forced me to participate in this program or activity.

I have made the decision to participate with full knowledge of my medical history and current medical status and, therefore, hold Cancer Care Services harmless from any injury, advancement of illness, or death from participation in the program designated below.

I understand that any injuries resulting from participation will not be considered the fault of Cancer Care Services, its employees, board of directors, officers, or instructors and are my responsibility.

I further indemnify and hold harmless Cancer Care Services and its assigns, officers, agents, servants, employees, directors, and subsidiaries from any and all claims, actions, demands, costs, liabilities, expenses and judgments whatsoever including reasonable attorney fees and costs which might arise in any manner from my participation in Cancer Care Services programs.

Cancer Care Services shall not be responsible or liable to the undersigned for any articles lost, damaged, or stolen in or about Cancer Care Services facility, adjoining premises or parking lot, or other program locations, or for loss or damage to any property, including, but not limited to, automobile and the contents thereof that may be left anywhere on the premises.

By his/her signature below, the undersigned hereby agrees to follow all of the rules of Cancer Care Services in the use of this designated facility, programs and equipment.

AGREED AND ACKNOWLEDGED by the undersigned for and in consideration of the right to use Cancer Care Services facilities, programs, and equipment on the date below.

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By signing below, I acknowledge the contagious nature of COVID-19 and voluntarily agree to the participation terms described above and assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending Cancer Care Services events and activities and that such exposure or infection may result in personal injury, illness, permanent disability, and death.

I understand that the risk of becoming exposed to or infected by COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to employees, volunteers, and program participants and their families.

I volunteer to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death) illness, damage, loss, claim, liability, or expense, of any kid, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at Cancer Care Services or Cancer Care Services programming. 

In addition, to signing this agreement, I acknowledge that Cancer Care Services is no longer requiring masks to be warn indoors, or outdoors for campers, employees and program participants. 

Furthermore, if you feel more comfortable as an employee, volunteer, or camper wearing a mask, both indoors and outdoors, or either, you are welcome to do so.  Parents, of campers, please also understand that it will be the responsibility of your child, and not staff or volunteers to wear their mask in the areas you prefer, and to keep up with their masks whereabouts, at all times. 

Cancer Care Services is following the current CDC recommended guidelines. 

I volunteer to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death) illness, damage, loss, claim, liability, or expense, of any kid, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at Cancer Care Services or Cancer Care Services programming.

Testimonial Statements:

By signing below, I give permission to Cancer Care Services (CCS)
and its affiliates to use statements shared through evaluation forms at special events, phone testimonials or written testimonials provided by me to CCS.
Cancer Care Services has my permission to use the statements in: official agency reports, advertisements, print, and/or online marketing. I understand that the above statements become the property of Cancer Care Services and that they may be used for: news, education, websites, online or social media, or other purposes related to the advancement of the program.

Photography/Videography:

By signing below, I give permission to Cancer Care Services (CCS)
and its affiliates to use photographs or video images of me from special events,
agency programs, email correspondence, or photo shoots arranged by CCS and/or images shared and posted by me to CCS-managed social media platforms. Cancer Care Services has my permission to use the images I provided or which were taken by the agency in: official agency reports, advertisements, print, and/or online marketing. I understand that the above images become the property of Cancer Care Services and that they may be used for: news, education, websites, online, and/or social media, or other purposes related to the advancement of the program.

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