March Break 2019

PARTICIPANT INFORMATION FORM(This document will be kept at each site and destroyed at the end of the week.)

INFORMATION ON THE PARTICIPANT (CHILD)

LAST NAME:      

First name:      

Sex: M F Other :

Child health insurance card number (RAMQ)—mandatory:      

Expiration date of the child’s health insurance card (YYYY-MM):      

Date of birth (YYYY-MM-DD):       Age:      

Address:       Apt.:      

City:       Postal code:      

Telephone:       Accès Gatineau card no.:      

Site:      

INFORMATION ON THE RESPONDENTS (PARENTS/GUARDIANS)

LAST NAME:       Father Mother Guardian

First name:      

Telephone 1:       Telephone 2:      

LAST NAME:       Father Mother Guardian

First name:      

Telephone 1:       Telephone 2:      

EMERGENCY CONTACTS

LAST NAME:      

First name:       Relationship to the child:      

Telephone 1:       Telephone 2:      

LAST NAME:      

First name:       Relationship to the child:      

Telephone 1:       Telephone 2:      

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PARTICIPANT’S ARRIVAL AND DEPARTUREThe child comes to the camp on his/her own (walks or bikes) Time of arrival:       Time of departure:      

Will the child have lunch at the site? Yes No

Individuals authorized to pick up the child (other than the respondents):

1. Name:       Relationship to the child:      

2. Name:       Relationship to the child:      

3. Name:       Relationship to the child:      

4. Name:       Relationship to the child:      

Will the child leave the facility for another activity (sport, music, etc.)?

Activity:       Day:       Time of departure:       Time of return:      

SWIMMING ABILITYWhen the program includes an outing to the pool, your child will be assessed by lifeguards to determine whether he/she requires a personal flotation device (PFD). Your child will be assessed on his/her first visit to the pool*.

For aquatic outings other than to the pool, there will be no assessment. The information provided by the parent in the personal information form will be the final word.

The following points will help you determine whether your child can swim without a PFD. Can your child:

YES NO DON’T KNOW

submerge his/her head?swim without constant supervision?

jump without hesitation into the deep part, and swim back to the surface without any sign of panicking?

tread water for 30 seconds without assistance?swim easily for 25 metres without assistance, without touching the edge of the pool, and

without resting his/her feet on the bottom?

If you answered “NO” to any of these questions, your child must wear a PFD.

YES NO

Regardless of the outcome of the assessment, I want my child to wear a personal flotation device (PFD) at all times during aquatic activities. If yes, the parent must provide the PFD.

*Please note that your child may be reassessed or required to wear a PFD if so requested by a monitor or a lifeguard.

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MEDICAL INFORMATIONALLERGIES:

YES NO

Hay fever

Poison ivy

Insect bites

Animals*

Medication*

*Specify:      

Does your child have an adrenalin dispenser on him/her (EpiPen, Ana-Kit) for allergies? Yes No

SIGN IF YOUR CHILD HAS AN ADRENALIN DISPENSERI hereby authorize the individuals designated by the Ville de Gatineau day camp to administer a dose of adrenalin ________________________ to my child in an emergency.

___________________________________________________

Parent’s signature

The child must at all times have his/her adrenalin dispenser (EpiPen, Ana-Kit) on him/her in a pouch attached to his/her waist.

PRESCRIPTION MEDICATIONS: YES NO

If yes, names of those medications:       Dose:      

Please note that your child must take his/her own medication. Staff will not administer any medication, other than epinephrine if the child is unable to administer it.

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MEDICAL INFORMATION (CONTINUED)SURGERY: Yes No

If yes, date (YYYY-MM-DD):      Reason:      

SERIOUS INJURY: Yes No

If yes, date (YYYY-MM-DD):      Description:      

CHRONIC OR RECURRENT ILLNESSES: Yes No

If yes, date (YYYY-MM-DD):      Description:      

Has your child ever had the following illnesses? Does your child suffer from any of the following?

YES NO YES NO

Chicken pox Asthma

Mumps Diabetes

Scarlet fever Epilepsy

Measles Migraines

Other, specify:       Other, specify:      

OTHER INFORMATIONThe following questions are designed to help us to better look after your child.

Does the child have physical or psychological limitations? Yes No

Specify:      

Does your child have behavioural issues? Yes No

If yes, please describe:

     

Does your child eat normally? Yes No

If no, please describe:

     

Does the child use a prosthesis? Yes No

If yes, please describe:

     

Are there activities in which your child cannot take part or can only do so under certain conditions?

Yes No

If yes, please elaborate:

     

Please note that all health information about your child will remain confidential, and will only be provided to his/her worker and the latter’s supervisor to ensure proper monitoring and response in case of an emergency.

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REFUND AND CANCELLATION POLICY

Registration fees are not refundable except: when Gatineau fails to fulfill its obligations; if the child who is registered moves away from Gatineau before the end of camp, in which case proof of the

move must be provided, and the refund will be based on the number of days used; or if the child cannot take part in the camp for health reasons (sickness or injury), in which case a medical

certificate must be provided, and the refund will be based on the number of days used.

OTHER

If your child must leave the site earlier than planned, you will have to provide written notification to the worker or person in charge of your child’s group on the day in question.

It is understood that parents agree to all of the risks of accident that may occur during day camp activities. Any damage to property or lost items are the child’s responsibility.

Consequently, I indemnify and hold harmless Ville de Gatineau, its officials and workers of any claim or legal action for any material damages, unless it is by intentional or major error.

I have read and understand the “Notification Procedure in Case of Inappropriate Behaviour on the Part of the Child”. I undertake to cooperate with the management of the Ville de Gatineau day camp, and to meet if my child’s behaviour is disruptive to the activities. I am aware that if my child displays inappropriate behaviour, he/she will have to suffer the consequences of his/her actions.

I have read and understand the information presented in the Day Camp Parent’s Guide.

I am responsible for informing camp management of any change in the information indicated on this form. I will provide this information to camp management, which will then follow up as appropriate with my child’s worker.

By signing this form, I authorize the Ville de Gatineau day camp to dispense first aid to my child. If Ville de Gatineau day camp management considers it necessary, I authorize my child’s transfer to a hospital or community health centre by ambulance or by any other appropriate means.

Signature:__________________________ Date: _______________

Important: This form must be filled out and handed in on the first day of camp.

It contains confidential information, and must remain at the site until the end of the day. It may not

be transferred to another site, which is why you must hand in a new form for each different site

attended during the week. If you wish to reuse it at the next site where your child is registered, you

can retrieve it on the last day.

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Express authorization by the legal guardians of a minor regarding the publication and use of a photo or audio or visual material

Being of legal age, I hereby authorize Ville de Gatineau to use the photo or filmed material of the minor person I legally

represent for use and publication in print or electronic documents such as flyers, newspapers, periodicals, bulletins,

posters, social media, Web site, videos and other documents of the same nature, year after year with no

compensation.

I indemnify Ville de Gatineau of any claim that may result from the use or publication of the document by anyone,

including third parties.

Print last and first names of the minor or minors photographed or filmed during the day camp.

1.       ___________________________________________________________________________

2.       ___________________________________________________________________________

3.       ___________________________________________________________________________

Print last and first name of the legal representative

     __________________________________________________________________________

I authorize: I do not authorize:

Signature of the consenting legal representative

     __________________________________________________________________________

Event: Day camp Location: Gatineau

Date: ________________________________ Photograph: _____________________

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Detachable Section for Official UseConfidential Information

This information will be included in your file held by the Service des loisirs and later deleted.

You can use one (1) form for the whole family.

FOR INCOME TAX PURPOSES

In order to receive a RL-24-T slip for your tax return, please submit the following information. This section is detachable, so please be sure to answer every question:

Payor’s last name:       Payor’s first name:      

Telephone 1:     Telephone 2:    

E-mail:    

Payor’s Accès Gatineau card number (mandatory):     

Payor’s social insurance number (SIN):            

Child/children’s last name(s): Child/children’s first name(s):

           

           

           

           

           

Authorization to communicate by e-mailI agree to have Ville de Gatineau contact me to obtain or provide information related to day camps.

If you require additional information, please contact your service centre:

Aylmer......................................................819-685-5007

Buckingham and Masson-Angers............819-931-2902

Gatineau...................................................819-243-4343

Hull...........................................................819-595-7400

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