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Camp Genesis: CIT Application Form
The
Counsellor-in-Training (CIT) program
is a job readiness and youth development program for 18-24 year-old young adults.
A registration fee of
R300.00
must accompany your application and is not refundable.
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PERSONAL DETAILS OF APPLICANT
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Name
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First
Last
Nickname
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Name applicant goes by
Applicant Cell No.
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Applicant Email
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Gender
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Male
Female
Other
Please specify.
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Date of Birth
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Proof of ID
*
ID Document
Passport
File Upload
*
Click or drag a file to this area to upload.
Upload a copy in PDF, PNG or JPEG.
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Are you still in School/College/Varsity
*
Yes
No
Please specify.
*
Do you have your own transport?
*
Yes
No
Do you have a Police Clearance certificate?
*
Yes
No
Have you attended Camp Genesis before?
*
Select
Yes! As a Camper
Yes! As a Camper and I am a returning LIT
Yes! As a returning LIT (but I was not a camper)
Yes! I was a Camper/LIT and in Camp Council
No! This is my first time at Camp Genesis
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Emergency Contact
*
First
Last
Relationship to Applicant
*
Select
Mother
Father
Stepmother
Stepfather
Legal Guardian
Grandmother
Grandfather
Sibling
Aunt
Uncle
Other
Please specify.
*
What is your relationship to applicant?
Emergency Contact Cell No.
*
Emergency Contact Email
*
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Are you involved in any other programs, clubs, or volunteer activities?
*
Make a selection
Yes
No
Briefly elaborate on other activity involvements
*
Character Reference
Please include one adult reference that can speak to your skill and talents as a potential CIT. Please ask them if they are willing to serve as your reference before submitting the application, and let them know that they will receive communication from us.
Reference Name
*
First
Last
Reference Email
*
Reference Phone
*
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Terms & Conditions
(including acknowledgment and assumption of risks and agreements of release and indemnity) Please read this document carefully. It informs you of certain activities of Camp Genesis and their risks, and affects your legal rights in the event of an injury or other loss. It must be signed by the Applicant and/or by his/her parent(s) or guardian (referred to below as "Parent"). Applicant signs to acknowledge certain understandings and Parent agrees to all provisions, for himself or herself and on behalf of the Applicant. This Agreement will continue in full force and effect for subsequent years and Camp terms for which Applicant registers, until and unless modified by written agreement. In consideration of the opportunity to participate in the Camp Genesis CIT program, Applicant acknowledges, and Parent acknowledges and agrees, as follows: Activities and Risks Applicant and Parent understand that Camp Genesis offers a variety of activities, including vigorous sports and games, water activities, exercise, fitness, and other activities, including crafts and creative projects. Risks of Camp activities are inherent in the Camp Genesis experience; that is, they cannot be eliminated without significantly altering the nature of the activities and reducing their value and appeal. These risks include those associated with motor vehicle travel, including by van and bus; exposure to the elements of nature, including heat, cold, rain, wind, lightning and fire; falls and abrupt and forceful contact with man-made and natural structures; close personal contact and physical trauma associated with sports and other recreation; falls, bites and other risks associated with errors of judgment, failure to follow instructions, and careless conduct of other campers, staff and other persons with whom the Camp may contract for certain services; and other risks ordinarily associated with camp activities and vigorous recreation in a rugged outdoor environment. Applicant may suffer cuts, fractures and sprains, insect bites, plant and other allergies, food and water related ailments, trauma from contact with other persons and objects, heat and cold from exposure to the natural elements, emotional upset and, in extraordinary cases, death, including by drowning. Other risks may be encountered, of course. We understand that the areas of the camp to which campers have access include a dam and river frontage, rocky, uneven and rugged wooded terrain, potentially harmful plants, and other creatures which sting or bite, all common to the Cape Winelands Biospheres. Camp activities may include travel off the premises to nearby towns and recreation opportunities in vehicles that may be furnished and/or driven by persons with whom the Camp has contracted for that purpose. The Camp accepts no responsibility for the performance of these drivers or their equipment. Acknowledgment and Assumption of Risks Applicant and Parent understand the activities and risks of the Camp experience, including those described above. Applicant and Parent (Parent, for himself or herself and on behalf of Applicant), acknowledge and assume all risks of Applicant's enrolment and participation in the activities of Camp Genesis, whether or not described above, and inherent or not. Release and Indemnity Parent, for himself or herself, and, to the maximum extent allowed by law, on behalf of the Applicant, agrees: a) to release, and not to sue, Camp Genesis, its owners, directors, staff (including volunteers and visiting instructors and clinicians) and independent contractors (each hereinafter a "Released Party") with respect to any and all liability and claims, for property loss, personal injury, death or otherwise, arising in whole or part from Applicant's enrolment or participation in Camp activities or presence on Camp premises. b) to hold harmless and indemnify (meaning to protect and pay claims and damages, including costs and attorneys fees) the Released Parties and each of them from and against all claims, by whomever they may be brought (including family members, fellow-campers and others) arising in whole or part from a loss incurred by Applicant or caused by Applicant related to his or her enrolment or participation in Camp activities or presence on Camp premises. c) These agreements of release and indemnity include, but not exclusively, claims based in whole or part on a Released Party's alleged or actual negligence (but not gross negligence or intentionally wrong conduct). Other a) The code of conduct set out in the Applicant/Parent Handbook must be strictly adhered to and Applicant may be dismissed from Camp, and sent home, in the event of violations of these or other requirements of the Camp Genesis administration. The rules are for the health, safety and welfare of all the campers and are strictly enforced. b) If a dispute arises between Applicant or Parent and the Camp which cannot be resolved by agreement, Parent, for himself or herself and on behalf of the Applicant, agrees to submit the dispute for mediation to a mediator registered with or otherwise recognized as such by the High Court of South Africa, Western Cape Division, Cape Town, where such mediation shall be conducted. c) Parent hereby gives permission to Camp Genesis to use photographs, videos or other images of Applicant for such purposes as the Camp deems appropriate, including promotional purposes in both print and digital media, and marketing of the camp. d) Parent understands that a non-refundable deposit of R300 is required to process the Applicant's CIT submission. e) The laws of the Republic of South Africa shall govern this agreement and all other disputes between Applicant, Parent and the Camp or any other Released Party. Any suit that might be filed against the Camp or any Released Party must be filed only in the High Court of South Africa, Western Cape Division, Cape Town. This agreement shall not be construed for or against a party because that party wrote it.
Checkboxes
*
Applicant have read this agreement carefully and understand its terms.
This form is complete to the best of my knowledge. I have read and agreed to all the terms and conditions. All information contained on this form will be kept on record, however should any information change between now and when your child attends camp please contact us immediately.
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Date
*
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