CAMP MARYDALE & URBAN HOOPS BASKETBALL CAMP
Please complete and deliver this form to the C.Y.O. office as soon as possible as space is limited. You can return your form
via mail, C.Y.O. 5999 Chippewa Road, Mount Hope, Ontario, L0R 1W0, email or fax, 905-528-9955.
Register Your Camper: (Complete one registration form per child) C.Y.O. Day Camps Costs $150.00 per week.
Child’s Name:
First MiddleInitial Last
Gender: M □ F □ Age: Birthday: ______/ ______/ ______School Name: Grade:
(current) mm dd yyyy (current)
Does your child have special needs and require ‘One-to-One’ care? Yes □ No □ (if uncertain please call)
Please identify your child’s disability: ______
Shirt Size:□Youth Extra Small □Youth Small □Youth Medium □Youth Large □Adult Small □Adult Medium □Adult Large □Adult XL
Home Address:
No. Street Name Apt. # City Postal Code
Home Phone #: E-mail Address:
Name of Mother/Guardian:Name of Father/Guardian:
Mother’s Phone: Father’s Phone:
Mother’s Cell/Bus: Father’s Cell/Bus:
Special Requests:
We will make every effort to place the following campers in the same group, provided the campers are the same gender and in approximately the same age range.
Name:______Age: _____ Gender: □M □F Name:______Age: _____ Gender: □M □F
Name:______Age: _____ Gender: □M □F Name:______Age: _____ Gender: □M □F
Declaration of Consent:
I (print name) ______, as the legal parent or guardian of (print child’s name) ______, through applying for registration for my child to attend C.Y.O. Camp Marydale or Urban Hoops Basketball Camp, hereby;
Give consent for my child to participate in all aspects of the camp program.
Understand that the Camp Director reserves the right to terminate the stay of any camper when it is deemed to be in the best interest of the child or the camp. In such cases proportional refund will be made.
Release and indemnify C.Y.O. Camp Marydale & Urban Hoops Basketball Camp and the Catholic Youth Organization of the Diocese of Hamilton from any and all claims for losses or articles and damages arising as a result of any accident, injury or otherwise sustained by the child named above during participation in the camp program.
Permit the use of the likeness of my child (in photographs, video etc) in promotional material by the C.Y. O. of the Hamilton Diocese.
Agree to the collection, use and storage of the information contained in this registration form as per the Privacy Policy of the Catholic Youth Organization. Copies of the policy are available at
The information is gathered for the purposes of registration, processing payment and ensuring camper health and wellbeing during the program.
Parent/Guardian Signature: ______Date: ______
Please complete this form by selecting your weeks, transportation and payment options on the following side.
Pick Your Session & Camp:
- Please select all the weeks you would like to send your child.
- You MUST select which camp you would like to send your child to,Marydale or Urban Hoops.
Dates: / Camp Choice (please select one): / Cost:
□ Week 1 –June 30th – July 4th / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 2 - July 7th – July 11th / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 3 - July 14th – July 18th / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 4 - July 21st– July 25th / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 5 - July 28th – August 1st / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 6 - August 4th – August 8th / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 7 - August 11th – August 15th / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
□ Week 8 - August 18th – August 22nd / □ Camp Marydale / □ Urban Hoops Basketball Camp / $150.00
Bus Pick-up & Drop-off Locations:
- All campers must use the bus transportation; please select ONE of the following stops closest to your residence.
- FREE bus transportation is listed below; all children riding the bus are supervised by camp staff.
- Bus’ will pick up campers between 8:00-9:00am and drop off between 3:30-4:30pm.
Ancaster / Binbrook / Caledonia / Dundas
□ Golf Links Rd. & Kitty MurrayLn.
□ St. Ann, Ancaster / □Bellmoore
□St. Matthew / □McKinnon Park
□ St. Patrick / □Ogilvie St. & Governor’s Rd.
□St. Augustine
Downtown Hamilton / Hamilton Mountain
□Britannia Ave. & Parkdale
□Canadian Martyrs
□Cannon & Gage
□Cannon & Kenilworth
□Cathedral C.S.S.
□St. Ann, Hamilton
□St.Columba (school closed) / □St. Eugene
□St. John the Baptist
□St. Joseph
□ St. Lawrence
□St. Luke
□St. Patrick / □Annunciation of Our Lord
□ Blessed Sacrament
□ Corpus Christi
□Miles Rd. & Rymal Rd.
□ Our Lady of Lourdes
□ Regina Mundi
□Sacred Heart
□ St. Jean de Brebeuf C.S.S. / □ St. KateriTekakwitha
□St. Margaret Mary
□ St. Marguerite D’Youville
□ Sts. Peter & Paul
□ St. Vincent de Paul
□St. Therese of Lisieux
□Upper Kenilworth & Landron
Mount Hope / Stoney Creek / Upper Stoney Creek / Waterdown
□Homestead Dr. & Airport Rd.
□Thames Way & Hampton Brook Way / □Our Lady of Peace
□Queenston Rd.& Lake Ave. □St. Clare
□St. David
□St. Francis
□Immaculate Heart of Mary / □Bishop Ryan C.S.S. (New)
□St. James
□St. Mark
□St. Paul / □Dundas St. E & Hamilton St. N □St. Thomas
□Winterberry/Paramount
Fees:
Per Session= $150.00
Deposit:$25.00 non-refundable deposit is required with this registration for each session of camp.
Balance: by cheque, money order or credit card due 21 days prior to camp. Pay to the order of C.Y.O.
Cancellation Policy: A $15.00 cancellation fee will be charged if a session is cancelled. / Method of Payment:
Cheque/Money Order for $______enclosed.
Make payable to C.Y.O.
Charge $ ______Visa or MasterCard
Charge the remaining balance of $ ______to my Visa orMasterCard 21 days prior to first day of camp.
Card Number: ______Expiry Date: month / day / year
Cardholder Name: ______
Cardholder Signature: ______
Questions about registration or camp?
Call: (905)528-0011 ext. 2229
Email:
On receipt of this registration and deposit a Confirmation Package will be sent to you.
How would you like to receive this confirmation package? Email Mail
Camper’s Medical Information Form:(this form must accompany the Registration Form)
Basic Information:
First Name:______Last Name: ______
Ontario Health Card #:□□□□●□□□●□□□●□□
Exact Name on Card: ______Date of Birth: month/ day /year
Name of Family Doctor: ______Telephone: (______) ______-______
Emergency Contacts:(other then parents/guardians listed on registration form)
1. Emergency Contact*: ______Relationship to Child: ______
Phone: (_____) ______-______
2. Emergency Contact*: ______Relationship to Child: ______
Phone: (_____) ______-______
*These people know my child and have agreed to be contacted in the event I am not available.
Medical Information:
All medication, vitamins etc must be turned over to the Wellness Coordinator at registration. They should be brought to camp in the original container, appropriately labelled for each camper.Please indicate if camper will bring his or her ownEPI Pen orInhaler.
Allergies: ______
Reactions: ______
Dietary Restrictions: ______
Medication (taken regularly): ______
Dosage: ______Time: ______
Has your child been immunized? Yes □ No □
Other Relevant Information:
Please describe other relevant medical information including health conditions not treated with medication, recent operations, illness or injuries this camper has had and give details: ______
______
Health Declaration and Emergency Authorization:
To the best of my knowledge, this camper is in good health, does not have a communicable disease and is able to participate in all aspects of the camp program. If he/she becomes exposed to any infectious disease four weeks prior to camp, I understand that the Camp Director must be notified in writing. I give permission for the medical information provided to be shared with the appropriate camp staff and outside medical personnel as necessary.
Authorization for Emergency Medical Treatment:
In case of an emergency and we are not immediately available for consultation, I hereby give permission to the physician selected by the Camp Director, to hospitalize, secure proper treatment for and order injections, anesthesia or surgery for my child, as named above with the cost of necessary prescriptions and medical expenses to be borne by me.
Name of Parent/Guardian (please print): ______
Signature of Parent/Guardian:______Date: ______