Program Registration Form

Input your dates:

Child First Name:

Child Surname:

Address:

City:

Postal Code:

Home Phone:

Email Address:

Age:

Emergency contact #1

Contact Name:

Contact Relationship:

Contact Home Telephone:

Contact Work Telephone:

Emergency contact #2

Contact Name:

Contact Relationship:

Contact Home Telephone:

Contact Work Telephone:

Health Information

Child DOB:

Health Card #

Physician Name:

Physician Telephone:

Dentist Name:

Dentist Telephone:

Allergies

Food:

Yes No

Insect bite:

Yes No

Drug:

Yes No

Carries Epipen:

Yes No

Please List specific allergies:

Please list specific reactions: (ie. rash, swelling, etc.)

Other Health Concerns

Is your child under any form of treatment/medication for any illness, condition or injury?

Yes No

If yes, please explain.

Please describe health concerns and any special care that your child may require

Behavourial Concerns

Are there any behavioural concerns our staff should be aware of with regards to your child?

Yes No

If yes, please explain.

Informed Consent

Waiver of Liability
1. In the event of an accident or medical emergency, I hereby authorize the leaders of the Explorations Green Summer Day Camp, or a person designated by them, to consent to any medical treatment by a qualified practitioner that may be necessary. I hereby release the staff and employees of the Environment Network and the Town of Collingwood from injury, loss or damage to any person or belongings incurred while at camp. I also understand that the use of the facilities of the Canteen at Sunset Point is made strictly at the risk of the applicant and agree to abide by the regulations governing the camp.

2. Pick up time is 4:30 pm. After 4:45 pm a fee of $1.00 per minute will be charged. In the event that a parent fails to arrive by 5:00 pm without prior notification Children’s Aid Society will be contacted.

3. Explorations Green Summer Day Camp has permission to use photographs/slides of my child for publicity purposes.

4. I understand that even under supervision, children can lose or damage their clothes and/or personal possessions. I release Explorations Green from liability for the loss or damage of my child’s clothes or personal possessions.

5. I state that my child is able in all respects to participate in all activities, including field trips throughout the Town of Collingwood. I give permission for my child to be transported by car driven by the Explorations Green coordinator under such circumstances that this may prove necessary.

I hereby certify that I have read and understand the Explorations Green policies and terms of enrolment.

PICK UP INSTRUCTIONS:
Please indicate below two authorized individuals who, in addition to parent/guardian(s) noted above, will be allowed to pick up your child from camp.

I authorize either of the following two individuals to pick-up my child in the event that I cannot make pick-up time. I understand that it is still my responsibility to notify camp staff in advance in this event.

Name

to child

Name

to child

Parent or Guardian's name submitting this form: