Camper Affinity Group Sign-up FY 2020

Camp Kesem will be offering a virtual affinity group for BIPOC campers (Black, indigenous and people of color) ages 11 and older.  Affinity groups are a space to connect with other Kesem members with an additional shared identity - in this case, race/ethnicity.  Camper affinity groups will be led by BIPOC staff, and include BIPOC campers from all over the nation. Think of these as an additional form of cabin chat, where the conversation is directed by campers. We are excited to spend time with our Kesem community!

To submit for multiple campers: after submitting the form for one camper, you'll have the option to fill out the form again for another camper(s) who would like to opt-in!
Camper Information




Note: currently only campers age 11 and older are able to participate



Parent/Guardian Contact Information




Additional Information









Participation Agreement

This CAMPER PARTICIPATION AGREEMENT is applicable to Camp Kesem’s alternative programming - camper affinity group virtual offerings. Please read the following CAMPER AFFINITY GROUP PARTICIPATION AGREEMENT carefully, including the Release of Liability and Assumption of Risk Agreement, which may deprive you of certain legal rights. By agreeing electronically, you acknowledge that you have reviewed, understand, and agree to all terms contained in the CAMPER AFFINITY GROUP PARTICIPATION AGREEMENT.

 

PARTICIPATION AGREEMENT 

This agreement includes:

  1. Release of Liability and Assumption of Risk Agreement

  2. Use of third-party software/applications

  3. Publicity Release

  4. Roster Release

  5. Arbitration Clause

  6. Dismissal From Affinity Group

  7. Confidentiality Agreement

  8. Camp Kesem’s Equity & Inclusion Statement

  9. Authorization of Verification of Information

 

In consideration of Camp Kesem allowing my child to participate in the activities Camp Kesem provides through affinity groups, I agree to the following:


  1. I understand that Camp Kesem employs certain individuals who may have training and/or certification in mental and behavioral health treatment and counseling. I acknowledge that to the extent that any Camp Kesem personnel consult or discussions with my child relating to my child’s mental, behavioral, or emotional health, they are specifically not entering into a therapist-client relationship with my child, and that neither Camp Kesem nor any of its agents, employees, or other personnel will provide counseling or any other mental health services to my child. Camp Kesem staff members are considered mandated reporters of suspected child abuse and neglect, and are required by law to share any such information they learn of during any portion of Camp Kesem affinity group programming. To the maximum extent allowed by law, I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS CAMP KESEM, ITS PERSONNEL, ITS CO-SPONSORS, AGENTS, AND REPRESENTATIVES, FROM ANY AND ALL LIABILITY TO MY CHILD OR ME ARISING FROM ANY CONSULTATIONS OR OTHER DISCUSSIONS THEY MAY HAVE WITH MY CHILD, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.


I understand that Camp Kesem affinity groups may contain discussions which focus on sensitive topics. As such, the content of discussions or the experiences shared by others in the affinity group may be emotionally charged, and potentially upsetting in nature. I understand that Camp Kesem will focus on maintaining a safe and empowering environment for my camper at all times during the affinity group, but cannot control what other participants say and discuss. I understand that participation in any emotionally charged discussions is entirely voluntary for my camper, and I agree to HOLD HARMLESS CAMP KESEM, ITS PERSONNEL, ITS CO-SPONSORS, AGENTS, AND REPRESENTATIVES, FROM ANY AND ALL LIABILITY TO MY CHILD OR ME ARISING FROM ANY CONSULTATIONS OR OTHER DISCUSSIONS THEY MAY HAVE WITH MY CHILD, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.


I understand that I am responsible for the safety of my home environment throughout my camper’s participation in Camp Kesem affinity groups. As the caregiver, I understand and acknowledge that I am responsible for maintaining a safe environment at home throughout my camper’s participation in Camp Kesem affinity groups programming.


I understand that I am responsible for my camper’s health and safety throughout their participation in Camp Kesem affinity group programming. In-person, Camp Kesem maintains rigorous safety protocols by trained staff and volunteers to ensure camper’s safety at all times. These same safety protocols are not possible in a virtual/online format. I understand that, while Camp Kesem is providing affinity group programming for my camper, it is not a replacement for childcare and supervision. I acknowledge that Camp Kesem cannot maintain the same level of safety procedures, and that maintaining supervision of my child’s health and safety is my responsibility in-person.


I understand that the exchange of personal identifying information (including email addresses, phone numbers, social media profiles, and any other identifying content) is not to be shared between my camper and Camp Kesem staff/volunteers. Camp Kesem staff/volunteers understand that asking for or soliciting the collection of personal identifying information of any camper is prohibited. I agree to ensure my camper respects this privacy requirement, and does not engage in the exchange/sharing of any personal identifying information with Camp Kesem staff/volunteers. In the event that personal identifying information is disclosed (such as if a phone number is displayed when calling in to a group call), Camp Kesem will not store or distribute this information in any way.


I acknowledge that Camp Kesem affinity groups programming is designed to help children build community and connections with other children who are like them and have shared experiences. These experiences are more effective and authentic when campers are able to connect with a group made up exclusively of their peers. For this reason, the only adults able to participate in Camp Kesem affinity groups programming are staff who have been selected, cleared a background check, and have completed required training provided by Camp Kesem National. I acknowledge that the programming performed at Camp Kesem affinity groups is provided only for my enrolled camper. I understand that, by signing this agreement, I am providing my consent for only my registered camper to participate in Camp Kesem affinity groups programming. I acknowledge that this is in the best interest of safety and privacy for both my camper and all other participants.


I understand that Camp Kesem affinity groups programming may position myself, or other members of my household, in proximity of Camp Kesem affinity groups programming which otherwise we would not be privy to. This may result in inadvertently gaining private information about other campers and Kesem community members. I agree to respect privacy and keep confidential any such private information inadvertently gained through proximity during Camp Kesem affinity groups programming.


I hereby give my permission for my child to attend all functions and activities Camp Kesem provides for Camp Kesem affinity groups programming. I understand that Camp Kesem may facilitate programming for my child with mailed items, digitally/online, or on the phone and that other children may be present during this programming. I understand and agree that outside companies hired by Camp Kesem may mail items related to Camp Kesem affinity groups programming  to the address provided in the camper application. I understand that Camp Kesem cannot control every conversation that may happen between my child and others, both during and after Camp Kesem affinity groups programming. I understand that Camp Kesem cannot control all risks associated with the mailing and receiving of items. To the maximum extent allowed by law, I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS CAMP KESEM, ITS PERSONNEL, ITS CO-SPONSORS, AGENTS, AND REPRESENTATIVES, FROM ANY AND ALL LIABILITY TO MY CHILD OR MYSELF, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, including, but not limited to, conversations which occur between campers that are outside of the control of Camp Kesem, and risks present with the mailing and receiving of items.

 

  1. As a part of Camp Kesem affinity groups programming, Camp Kesem may engage campers using a variety of software platforms and applications. This includes, but is not limited to, Zoom video conferencing, Instagram, Facebook, and TikTok. While Camp Kesem will take every measure to protect the privacy of their campers and families, Camp Kesem cannot control the privacy and security measures of these third party applications. As the parent/caregiver, I understand that the decision to join any platform belongs to me and my camper. I acknowledge that I am aware of and accept any risks associated with joining and using any of these applications/platforms, and  I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS CAMP KESEM, ITS PERSONNEL, ITS CO-SPONSORS, AGENTS, AND REPRESENTATIVES FROM ALL CLAIMS, DEMANDS, AND CAUSES OF ACTION THAT MY CHILD OR I MAY HAVE BY USE OF THESE PLATFORMS.


  1. I give my consent and permission to Camp Kesem, Camp Kesem National, and any other of their partners or affiliates to use or authorize the use of my child’s name and likeness, including photographs, videos, interviews, or other publicity-related items involving my child, for promotional, marketing, or any other uses. I further agree that I have no right, title, or interest in the materials described herein, and I authorize Camp Kesem to reproduce and/or make derivative works from, as well as reasonable edits and alterations to, the materials.  I waive any right to inspect or approve the finished product or materials in which Camp Kesem, Camp Kesem National, or any of its partners or affiliates may eventually use my child’s voice, image, and/or likeness.  Further, I understand that, although Camp Kesem will endeavor to use my child’s likeness in accordance with the standards of good judgment, Camp Kesem cannot warrant or guarantee that any further dissemination of my child’s likeness will be under Camp Kesem’s supervision or control. To the maximum extent allowed by law, I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS CAMP KESEM, ITS PERSONNEL, ITS CO-SPONSORS, AGENTS, AND REPRESENTATIVES FROM ALL CLAIMS, DEMANDS, AND CAUSES OF ACTION THAT MY CHILD OR I MAY HAVE BY REASON OF THIS AUTHORIZATION.   If, for any reason, I do not want any such items involving my child used in promotional, marketing, or other materials, I will notify Camp Kesem in writing before my child’s first day of camp.  

 

  1. I give my consent and permission to Camp Kesem, Camp Kesem National, and any other of their partners or affiliates to distribute my contact information via a Camp Kesem affinity groups roster to other campers and families that attend Camp Kesem.  If, for any reason, I do not want my contact information to be distributed via a Camp Kesem affinity groups roster to other campers and families, I will notify Camp Kesem in writing before my child’s first day of Camp Kesem affinity groups.

 

  1. I agree that any dispute concerning, relating to, arising from, or referring to the subject matter of this Agreement or otherwise, shall be resolved exclusively by binding arbitration in the state and county where my child is participating according to the then-existing commercial rules of the American Arbitration Association and the substantive laws of that state, unless Camp Kesem selects a different forum, which it may do in its sole discretion.

 

The arbitrator, and not any federal, state, or local court or agency, shall have exclusive authority to resolve any dispute relating to the interpretation, applicability, enforceability, conscionability, or formation of this Agreement, including, but not limited to, any claim that all or any part of this Agreement is void or voidable.  If any provision of this Agreement or the application thereof to any person or circumstance shall, for any reason and to any extent, be invalid or unenforceable, the remainder of this Agreement and the application of that provision to other persons or circumstances shall not be affected, but rather shall be enforced to the maximum extent permitted by law.  Each obligation or other provision of this Agreement shall be deemed and construed independently, and shall not be deemed to be dependent on any other provision of this Agreement.  

 

  1. Rarely, we find that we need to dismiss children from Camp Kesem affinity groups programming  in situations where continued participation may impact the safety/Camp Kesem affinity groups experience of themselves or others. At Camp Kesem affinity groups, this may include (but is not limited to):

Behavioral issues which fall outside of the scope and training of our counselors and staff, failure to comply with pre-program behavioral plan, or behaviors that make others feel unsafe.

Camp Kesem will use its discretion to determine if a dismissal from Camp Kesem affinity groups participation is necessary for: 

  • Violence (including threats of violence, or conversations regarding violence during programming)

  • Drugs or alcohol, including any tobacco product (vapes, e-cigarettes, etc.)

  • Weapons

  • Threats to themselves or others - this includes running away

  • Negative comments or jokes regarding one’s race, religion, sexual orientation, or gender identity

    • If these comments are made, Camp Kesem staff will discuss with the camper the consequences - this will result in a call with the parents/caregivers and if any additional comments are made, a shortened participation


  1. Camp Kesem believes that connections form during  Camp Kesem affinity groups  programming in a more meaningful way when campers feel comfortable speaking openly with their counselors/Kesem staff. As a result, Camp Kesem will maintain the confidentiality of discussions shared during programming. 


Additionally, Camp Kesem staff are mandated reporters. meaning that if we reasonably suspect that a child is being abused, we are required to contact the appropriate authorities without doing any further investigation, and that we will not disclose this fact to you when the source of that suspected abuse is at home or by a person known by the parent.


An exception to confidentiality is provided if your child poses a current threat of harm to themselves or to another person. In such cases, Camp Kesem will take whatever steps are required by law, or permitted by law, to help prevent the potential harm from happening, including notifying the parent(s)/guardian(s), respective child protective services, or medical professionals.


I understand that Camp Kesem will notify me of any situations that may arise during Camp Kesem affinity groups programming in which my child shares information that presents a current risk/danger to self or others. I understand that Camp Kesem is required to comply with all child protective laws, and may not always be able to share information with me.


  1. Kesem’s mission of supporting children through and beyond a parent’s cancer, and our vision of ensuring that every child impacted by a parent’s cancer is never alone, can only be realized through an ongoing, steadfast commitment to Diversity, Equity, and Inclusion in every part of our organization.

To that end, Kesem makes the following commitments:

  • To continually expand the communities we support and work with - our camper families, volunteers, staff, alumni, and supporters - with attention to engaging underrepresented communities.

  • To strive for equity in delivering a transformative, healing, and empowering experience to those communities that recognizes and embraces our differences in race, religion, ability, nationality, sexual orientation, gender expression and identity, family structure, cancer stage or type, or socioeconomic status.

  • To work to ensure that every member of the Kesem community feels safe, loved, and respected.

Kesem fulfills its commitment to Diversity, Equity and Inclusion through daily efforts in the following areas:

  • Hiring and Professional Development

  • Camp, Year-Round Programming, and Camp Kesem affinity groups programming

  • New Program Development

  • Program Evaluation

  • Chapter Expansion

  • Recruitment of camper families, volunteers, board members and supporters

These efforts are vital to Kesem’s continued success and will be pursued with passion and a lasting pledge to continually improve.


  1. By signing this agreement, the undersigned affirms that they agree to the terms and conditions of this application. 


By signing this agreement, the undersigned attests that they are the parent or guardian of the participant and have full power and authority to enter this agreement on behalf of the participant. 


By signing electronically below, the undersigned accepts and agrees to these terms on behalf of themselves and the participant, and agrees that this electronic version shall have the same force and effect as a written original.