Relay For Life Caregivers' Lap Form - Canadian Cancer Society

Office use only
Unit #: ___________Team #: _________
Relay For Life Caregivers’ Lap Form
Caregivers are family, friends or members of the community who are currently caring
for or who have cared for someone with cancer. All caregivers are invited to walk one of
the first laps of Relay For Life, the Caregivers’ Lap to be recognized for the support
they give or have given a loved one.
Caregivers and cancer survivors are also invited to a special Survivors’ Reception.
Event location: F.H. Sherman Recreation & Learning Centre (Dofasco Park)
Date and time: Friday June 7 - Saturday June 8 7 p.m. - 7 a.m.
Caregivers and cancer survivors are requested to arrive on Friday between 5:00-5:30
pm. Dinner will be at 5:30 pm and the Opening Ceremony will begin at 7:00 p.m.
Please complete the following form:
First name:______________Last name:_________________Team Name:_____________
Address: ________________________________________________ Apt #: __________
City: ________________________ Province: ____________ Postal code: ____________
Home tel: (____)______________________ Bus tel: (____)_______________________
E-mail: __________________________________________________________________
The Canadian Cancer Society provides supporters with updates on how their efforts are making a difference in the lives of
Canadians fighting cancer, as well as opportunities to join the fight against cancer.
Yes. I would like to receive e-mail updates from the Canadian Cancer Society.
You can change this option at any time by contacting privacy@ontario.cancer.ca
Please return form to your local Canadian Cancer Society office.
Canadian Cancer Society Hamilton-Wentworth Unit
328 Mountain Park Ave
Hamilton, ON L8V 4X2
(905) 575-9220
Fax: (905) 575-3370
Would you like further involvement with the Canadian Cancer Society
(Please check all that apply)
Enter a team in Relay For Life
Join the Relay For Life Committee
Volunteer for the Canadian Cancer Society
I’m already involved! If so, how ___________________________________________

Relay For Life
Caregiver Permission and Release Agreement
By participating in the Canadian Cancer Society’s Relay For Life event:
I grant permission to the Canadian Cancer Society to photograph and videotape me in the
course of my participation in the Relay For Life event, and to use my name and any
photographs and videotapes of me for Canadian Cancer Society purposes in any media
and territory in perpetuity.
I waive and release any and all claims for myself, my heirs, executors and administrators
against the Canadian Cancer Society, its agents, employees and licensees and any
sponsors, officials, volunteers and organizers of the Relay For Life event in connection
with any injury, illness or death, or loss or damage to property, which may directly or
indirectly result from my participation in this event, and any claim arising in connection
with the use of my name or any photographs or videotapes of me.
I acknowledge that I will not receive any financial remuneration for any of the above and
that my compensation is the opportunity to participate in the event and contribute to the
activities of the Canadian Cancer Society. I warrant that I am fit to participate in this
event.
I have read and fully understand and agree with the contents of this Agreement, prior to
participating in the Relay For Life event.
Name of Caregiver:________________________________________________________
Address of Caregiver:______________________________________________________
Telephone number of Caregiver:______________________________________________
Signature of Caregiver:________________________ Date:_______________________
The Caregiver Permission and Release Agreement must be signed by each caregiver.
If a caregiver is under 18 years of age then a parent /guardian must sign the
Agreement on the caregiver’s behalf. Caregivers who have not signed the Agreement
will not be able to participate in Relay For Life.
Name of guardian(s) authorized to sign for caregiver:
Address of guardian(s):
______________
______________
Telephone number of guardian(s):____________________________________________
Signature of guardian(s): ________________ Date: _______
We respect your privacy. The Society collects your personal information in order to process your registration
in the Caregivers’ Lap. We may also contact you from time to time with information about other ways you can
help us in our fight against cancer. If you prefer not to receive this kind of communication from us or for more
information about our privacy practices: www.cancer.ca * 1 800 268-8874, x2257 * e-mail:
privacy@ontario.cancer.ca.