camp_child_info_form_2012

Crescentwood River Heights Sir John Franklin

1170 Corydon Ave 1370 Grosvenor Ave 1 Sir John Franklin Road Phone: (204) 452-9844 Phone: (204) 488-7000 Phone: (204) 489-9537 Fax: (204) 284-2695 Fax: (204) 488-3224 Fax: (204) 489-1720

www.centralcorydoncc.com

SUMMER CAMP REGISTRATION FORM

Registrant’s Name: ____________________________________________ Male______ Female_____

Birth date: _____(day) _____(month) _____(year)

Address: _________________________________________________________________________________________

City: _______________________ Province: __________________ Postal Code: ____________________________

Home Phone Number: __________________________

Parent/Guardian’s Name:_______________________ Alt. Phone Number: ____________________________

Parent/Guardian’s Name:_______________________ Alt. Phone Number: ____________________________

Email Address: ___________________________________________________________________________________

Family Medical #:__________________ (6 digits) Personal Medical #:__________________________(9 digits)

EMERGENCY CONTACTS

AND PICK-UP AUTHORIZATION

The following people should be contacted in case

of emergency only if parent(s) or guardian cannot

be reached AND are authorized to pick up the

child:

1. Name: ____________________________________

Relationship to child:_________________________

Phone: Day (_____)____________________________

Evening (_____)________________________

2. Name: ____________________________________


Phone: Day (_____)____________________________

Evening (_____)________________________

3. Name: ____________________________________


Phone: Day (_____)____________________________

Evening (_____)________________________

Does your child have any allergies, medical

restrictions, or difficulties of any kind (i.e. hearing,

speech, vision, behaviour) that we should be

aware of: (please be specific)

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________




CONSENT TO COLLECT, USE, AND DISCLOSURE OF PERSONAL INFORMATION

I understand that, by completing this form the Central Corydon Community Centre is collecting certain

personal information about my child, me and other members of my family (including, if necessary, my

Manitoba Health Services Registration Number).

I also understand that this personal information will be used only for the purpose of registering in the

Community Centre’s Sport/Recreation/Youth Programs, and that such use will necessarily involve the

disclosure of this personal information to the appropriate area sport association(s) and/or the appropriate

sport umbrella group(s), Coach(es), Manager(s), Staff and the use of such disclosed personal information by

such association(s), group(s), Coach(es), Manager(s) and Staff as may reasonably be required in order to

conduct the Community Centre Sport/Recreational/Youth Programs.

I hereby consent to such collection, use and disclosure of this personal information.

Name of Registrant: __________________________________________________________________________________

Printed Name of Parent or Guardian of Registrant: ____________________________________________________

Signature of Parent or Guardian: __________________________________________ Date: __________________

PARENT/GUARDIAN AUTHORIZATION

I/We the parents/guardians of ______________ do hereby give my/our consent for him/her to participate in

the program selected above. I/We understand that Central Corydon Community Centre, or its instructors will

not be held responsible for any accident, injury or loss, however cause and to agree to release the aforesaid

from all claims or damages which may arise as a result of, or by reason of, such accident, injury, loss or

medical expense.

1. In the event that my child needs immediate medical attention for injuries received while participating in a

C4 program, I authorize the staff to give my child reasonable first aid, and to arrange transport of my child to

a health care facility for emergency services, and to release medical information to medical providers as

needed.

2. My child has my permission to attend and participate in all C4 Summer Program Field Trips whether they

are walking or being transported by bus.

3. I hereby acknowledge that the C4 will assume that either parent of the child may pick up the child at

any time during the program unless there is pertinent court documentation on file at the C4 office that

indicates otherwise.

4. I hereby release all pictures of my child taken by the C4 for promotional purposes and programming

materials.

5. If my child requires use and administration of an epi-pen, it is my responsibility to ensure that the epi-pen is

on my child or within their personal belongings every day of the program. If C4 staff are

required to administer and use the epi-pen, I agree to forever release and discharge the C4 and it’s

directors, officers, and employees from any and all liability arising out of or resulting from use or

administration of the epi-pen.

6. I give my permission for the C4 Staff to administer sunscreen as needed.

Name of Registrant: __________________________________________________________________________________

Printed Name of Parent or Guardian of Registrant: ____________________________________________________

Signature of Parent or Guardian: __________________________________________ Date: __________________




SUMMER CAMP REGISTRATION FORM

Which weeks of camp are you registering for:

Sports Camp (6-12 years old)

□ July 3rd-6th: Ultimate Field Sport Week

□ July 9th-13th: Tennis

□ July 16th-20th: Flag Football

□ July 23rd-27th: Baseball

□ July 30th-August 3rd: Floor Hockey

□ August 7th-10th: Racquet Sports

□ August 13th-20th: Outdoor Adventure

□ August 20th-24th: Dodgeball

□ August 27th-31st: Sports Bonanza

Specialty Camp (6-12 years old)

□ July 3rd-6th: Artful Antics

□ July 9th-13th: Field Trip Camp

□ July 16th-20th: Lights, Camera, Action

Drama Camp

□ July 23rd-27th: Clowning Around

□ July 30th-August 3rd: Zumbatronic Party Camp

□ August 7th-10th: No Bake Kids in the Kitchen

Day Camp (6-12 years old)

□ July 3rd-6th: Around the World in 5 Days

□ July 9th-13th: Who Dunnit'?

□ July 16th-20th: Game Show Mania

□ July 23rd-27th: Holiday Hoopla

□ July 30th-August 3rd: Get Messy

□ August 7th-10th: Adventure Explorers

□ August 13th-20th: Greek Greatness

□ August 20th-24th: Splish Splash Water Week

□ August 27th-31st: Lets Make some Noise

and Show some Spirit

Tot Camp (3-5 years old)

July 3rd-6th □Full Day □ ½ day am □½ day pm

July 9th-13th: □Full Day □ ½ day am □½ day pm

July 16th-20th: □Full Day □ ½ day am □½ day pm

July 23rd-27th: □Full Day □ ½ day am □½ day pm

July 30th-August 3rd: □Full Day □ ½ day am □½ day pm

August 7th-10th: □Full Day □ ½ day am □½ day pm



August 27th-31st: □Full Day □ ½ day am □½ day pm

Documents

camp_child_info_form_2012