Outdoor Leadership Camp
For 9-12 year olds!
:
Check off weeks attending:
CHILD'S PERSONAL INFORMATION
NAME:______
LAST NAMEFIRST NAMEMIDDLE NAME
ADDRESS:______
NUMERSTREETUNIT/APT. NUMBER ______CITY PROVINCE POSTAL CODE
TELEPHONE:______DATE of BIRTH:______
MONTH DAY YEAR
PARENT PERSONAL INFORMATION
PARENT/GUARDIAN 1 MALE FEMALE PARENT/GUARDIAN 2 MALE FEMALE
NAME:______
ADDRESS:______
TELEPHONE:______
CELL PHONE:______
EMPLOYER:______
EMAIL:______
TELEPHONE:______
EMERGENCY CONTACT INFORMATION
NAME:______RELATION:______
ADDRESS:______
TELEPHONE:______
HOMEBUSINESS
NAME:______RELATION:______
ADDRESS:______
TELEPHONE:______
HOMEBUSINESS
BUS LOCATION UTILIZING (IF APPLICABLE):
LINCOLN ALEXANDER SPC:______GLEN DHU SPC______
AM: PARENTS MUST WAIT AT BUS LOCATION UNTI BUS PICK UP / PM: PARENT MUST BE PRESENT FOR DROP OFF
CHILD'S MEDICAL INFORMATION
DOCTOR(S):______TELEPHONE:______
ADDRESS:______
HEALTH CARD NUMBER for CHILD:______EXPIRY DATE:______
(OPTIONAL—to be used for emergency purposes only)
SPECIAL MEDICAL CONDITIONS/ALLERGIES: ______
______
MEDICATION ADMINISTERED on a REGULAR BASIS: ______
______
ADDITIONAL INFORMATION: ______
______
MEDICAL CONSENT
I, ______the parent/guardian of ______
PARENT/GUARDIANNAME of CHILD
Do hereby authorize the staff of Schoolhouse Playcare Centres of Durham to consent to any necessary life saving medical or surgical treatment which may be required for my child, in the opinion of a licensed medical practitioner, to the extent necessary to preserve life until the parent/guardian can be contacted.
______
SIGNATURE of PARENT/GUARDIAN DATE
PERMISSIONS
I GIVE PERMISSION FOR MY CHILD TO GO ON BUS TO AND FROM CLARMONT FIELD CENTRE ______(INITIAL)
I AUTHORIZE THE USE OF CAMP SUNSCREEN IN THE EVENT CHILD’S OWN IS LEFT AT HOME
I AUTHORIZE THE STAFF OF SCHOOLHOUSE PLAYCARE CENTRES TO SHARE RELEVANT INFORMATION ABOUT MY CHILD WITH THE APPROPRIATE STAFF MEMBERS AT CAMP AS THE NEED ARISES.
I GIVE PERMISSION FOR PHOTOGRAPHS/VIDEO TAPES TO BE TAKEN OF MY CHILD BY A STAFF MEMBER FOR USE WITHIN THE ORGANIZATION.
I GIVE PERMISSION FOR PHOTOGRAPHS TO BE USED FOR SHARING MY CHILD’S CAMP EXPERIENCE WITH OTHER FAMILIES ENROLLED IN THE CAMP.
I GIVE PERMISSION FOR PHOTOGRAPHS/VIDEO TAPES TO BE TAKEN OF MY CHILD BY THE MEDIA OR OTHERS FOR USE OUTSIDE THE ORGANIZATION.
______
SIGNATURE OF PARENT/GUARDIAN
Schoolhouse Playcare Centres of Durham respects the privacy of its clients, employees and volunteers and will act responsibly in the collection, handling and storage of personal information. Personal data is collected in order to better meet clients’ needs, to ensure safety, to inform clients of service information and to comply with any government or regulatory obligations. For more information on our Privacy Policy, please contact the Executive Director at (905) 728 7740.
Summer Camp Registration May 2016 ` Page 1 of 2