I am the parent/guardian of the minor child(ren) indicated on the 1199SEIU Anne Shore Sleep-Away Camp Program 2020 Application, and I hereby give permission for my child(ren) to participate in the 1199SEIU Anne Shore Sleep-Away Camp Program.
I understand that while the 1199SEIU National Benefit Fund, through the 1199SEIU/Employer Child Care Corporation (together “1199SEIU Funds”) are providing payment or reimbursement for this program, the 1199SEIU Funds are not running the program, but are contracting with different camps/organizations (“Providers”). I acknowledge that the 1199SEIU Funds assume no responsibility whatsoever for the manner in which the program is conducted, the activities that may be performed or any other matter related to or arising out of the program. 1199SEIU Funds solely verifies that the participating camps/organizations hold valid permits, licenses and accreditations where applicable. I further acknowledge that the participating camps/organizations are not endorsed by the 1199SEIU Funds. Therefore, in exchange for the 1199SEIU Funds’ payment for my child(ren)’s participation in the program, I release and discharge the 1199SEIU Funds and any of their Trustees, officers, employees, affiliates, successors, assigns, and agents (whether acting in their individual capacity or as agents of the 1199SEIU Anne Shore Sleep-Away Camp Program and/or 1199SEIU Funds) from any and all liability, responsibility or claims (including but not limited to, claims for negligence) present and future, known or unknown pertaining to any accident, injury, damage, or loss to person or property which may occur during the course of my child(ren)’s participation in the program.
Should my child require emergency medical attention, I hereby give my consent to the medical provider.
Most providers include transportation to and from the camp; if they do not it is the parent’s responsibility. If a child is withdrawn or dismissed early, the parent is responsible for the means and cost of transportation.
Media Release
I hereby give permission for my child(ren) to be photographed and/or videotaped while participating in the program and agree that these photographs and/or video images may be used by the 1199SEIU Anne Shore Sleep-Away Camp Program and/or the 1199SEIU Funds or 1199SEIU United Healthcare Workers East (my union), or its related entities for promotional materials.
Application and Participation
I understand that a $50.00 administrative fee (cash or money order only) is due for each child at the time of benefit distribution. I also understand that my failure to do so will jeopardize my child(ren)’s participation in the 1199SEIU Anne Shore Sleep-Away Camp Program. I acknowledge that while the 1199SEIU Anne Shore Sleep-Away Camp Program is tailored to meet the needs of members and their families, only one child per family may be eligible to attend, except in the case of multiple birth children, who may be eligible to attend together. I also understand that when space allows, the children of returning members or a second child from the same family will be given the opportunity to attend camp.
Should I for any reason decide not to have my child(ren) participate in the Anne Shore Sleep-Away Camp Program during the 2020 program term, I will notify the 1199SEIU Funds in writing (fax to 646-473-8311, email to AnneShoreCampProgram@1199Funds.org, or mail to 330 West 42nd Street, 32nd Floor, New York, NY 10036) by May 29, 2020. I understand that if I do not notify the 1199SEIU Funds by May 29, 2020, the 1199SEIU Funds will have no other alternative than to report the value of the camp benefit to the Internal Revenue Service (IRS) as wages (Form W-2), just as if my child(ren) had attended camp. I also understand that my failure to do so will jeopardize my child(ren)’s participation in future camp experiences offered by the 1199SEIU Anne Shore Sleep-Away Camp Program.
Taxable Benefit
I hereby acknowledge that the IRS has determined that the 1199SEIU Anne Shore Sleep-Away Camp Program is a Taxable Benefit and that I will receive a Form W-2 from the 1199SEIU Funds at the end of the year that will represent the value of the camp benefit. I understand that this amount must be included when I file my tax return.
