Limestone District School Board

Limestone District School Board

Free Numeracy & Basketball Camp – Grades 7-10

Registration Form

*All fields must be completed. If a section does not apply, please mark with “N/A”

Note: This camp runs from 9:00am-4:00pm. Open to students entering grades 7-10 in Fall 2017

Please note your preference of camp. Space will be confirmed by Boys and Girls Club.

We will try out best to accommodate your preference selection. At this time you may only register for one week.

Return completed form to Boys and Girls Club (1300 Bath Road) or scan to

Note: this camp requires a minimum of 15 participants to run

Camp Dates / Location of Camp / Preference Selection (X)
July 17th-21st / Loyalist Collegiate and Vocational Institute
153 Van Order Drive
July 24th-28th / Frontenac Secondary School
1789 Bath Rd

Student Information:

Student’s Last Name / First Name
Address – Street no. - Apt / City – Postal Code
Home Telephone
( )
Date of birth (long form: day/month/year) / Age Gender
School Name / Grade Entering in Fall 2017
Doctor’s Name – Phone Number& Address
Is the student already a registered member with the Boys and Girls Club of Kingston & Area? Yes No

Family Information:

Student resides with: Both Parents Father Mother Guardian
Mother/Guardian (last name and first name) / Father/Guardian (last name and first name)
Address Same as student / Address Same as student
Telephone (cell phone) / Telephone (cell phone)
Employer / Employer
Work phone number / Work phone number
e-mail address / e-mail address
Siblings who are registered Members None

Emergency Contact (other than parent/guardian) & Pick-Up Privileges:

Last Name First Name Relationship to Student
Home Phone Cell phone
In order for your child to be permitted to leave the premises, a parent/guardian or someone (aged 14 years or more) authorized by the parent/guardian must come in the building to sign them out. Please list who can pick up your child.
Name / Home Phone / Relationship to Student
Limestone District School Board & The Boys & Girls Club of Kingston & Area is fortunate to provide barrier-free programming due to our funders, can you please assist us in obtaining additional information about the children we serve. Do you consider your child to be included in any of the following groups? (check all that apply)
Immigrant/New Canadian / Rural Resident / Visible minority
Francophone / First Nations/Métis/Inuit / Person with disability
Military Family / Single parent home / Other:
Additional Information:
Does your child/youth have any special needs in any of the following areas? Please indicate any medications they are taking and diagnosis when applicable.
Physical: No Yes, please explain:
______
Learning: No Yes, please explain:
______
Behavioural: No Yes, please explain:
______
Please note that if any medication needs to be administered during program hours, the Permission to Administer Medication Form must be completed and attached to this form.
Does your child have any allergies? No Yes, please complete the chart below
Does your child have any dietary restrictions? No Yes, please complete the chart below
Allergen/Restriction / How severe? (physical contact, ingested, inhaled) / Epipen location (N/A if not needed)

Swimming Information

Children aged 12 are required to pass a swim test in order to swim without a life jacket in the pool. ______Initial

Sunscreen

I understand that I am to provide my youth with sunscreen each day, complete with a label stating the students’ name. Youthwill be required to apply sunscreen before going outdoors. ______Initial

Electronics/Personal Items

Limestone District School Board & The Boys and Girls Club of Kingston & Area is an “electronic free” space. We do not allow students to bring or use cell phones, gaming devices, ipods or mp3 players, digital cameras etc. Limestone District School Board & The Boys and Girls Club is not responsible for stolen money or valuables that are brought to camp. ______Initial

Photo Waiver

I am aware that my child may have his/her photograph taken by staff or local media and may appear in a variety of media sources on behalf of the Limestone District School Board & Boys and Girls Club Kingston & Area. ______Initial

IF YOU DO NOT WANT YOUR CHILDS PICTURE TAKEN PLEASE CHECK THE FOLLOWING BOX:

Behavioural Management Policy

Limestone District School Board & The Boys & Girls Club of Kingston and Area reserves the right to remove any child from any program to ensure the safety and well-being of other participants, should we deem it necessary. ______Initial

I will impress upon the child the importance of following club rules, regulations and instructors directions ______Initial

General Program Waiver

I, the undersigned, the parent/guardian of the above named child do hereby consent to this child’s participation in theLimestone District School Board & Boys Girls Club of Kingston & Area’s programs. I acknowledge that participation in these programs involves light to vigorous activity and includes the possibility of injury. I grant program officials the authority to obtain emergency medical treatment as necessary to ensure that the above named child is safe from further injury. I am aware of no physical or other reasons why this child should not participate in club programs and related club functions. The risk of sustaining injuries results from the nature of the activity and can occur without any fault of either the Member/Student, or the Club, its employees/agents or the facility where the activity is taking place. By choosing to take part in this activity, Iam accepting the risk that my child may be injured. Limestone District School Board & The Boys and Girls Club of Kingston and Area does not provide accidental death, disability, dismemberment or medical expense insurance on behalf of the participants in this activity. In consideration of Limestone District School Board & the Boys & Girls Club of Kingston & Area, allowing this child to participate in club programs, I agree to waive and release Limestone District School Board & Boys & Girls Club of Kingston & Area its employees, volunteers, directors and agents from all claims for damages, injury or loss that may arise as a result of my child’s participation in programs.______Initial

Transportation Waiver

I acknowledge that my child (children) will be participating in an activity, trip or event organized by Limestone District School Board & the Boys and Girls Club of Kingston & Area. I am aware that the participation of my child (children) is outside the scope of their daily routine. I give permission for my child (children) to travel by foot, Limestone District School Board or Boys and Girls Club Van, or Bus to the desired destination.______Initial

Signature of Parent/Guardian ______Date: ______