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Indigenous Math Leadership Summer Camp 2018

Indigenous Math Leadership Summer Camp is a free 2 week day camp for children and

youth that is designed to help develop confidence with their math ability and embrace

Indigenous culture. This program addresses summer learning loss and is a fun and

engaging way for youth to increase mathematical literacy. Activities include math

lessons, computer coding, 3D printing, Lacrosse, Anishinaabe cultural and language

learning as well as field trips. The camp is divided into two sessions of two week long

camps over the month of August, with each divided into age groups: Grade 1-3 (age 6-9)

and Grade 4-6 (10-13).

Camp dates:

- July 30-August 10 Math Camp for youth in Grade 1 to 3

- August 13-24 Math Camp for youth in Grade 4 to 6

Indigenous Math Leadership Camp will run from 9:00-4:00 every day with breakfast,

lunch and snack provided.

Please fill out the registration form completely and turn it in to the Program

Coordinator, Julie Hiebert, as soon as possible as space is limited.

The registration form can be submitted in many ways:

- In person at the Wii Chiiwaakanak Learning Centre (511 Ellice) Tuesday – Friday

10:30-4:30

- Via fax at 204.783.4992

- Via email at j.hiebert@uwinnipeg.ca

Once the application is processed you will be notified with a confirmation.

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Indigenous Math Leadership Camp Informed Consent

Form Participant Information

First Name: Last Name:

Birth Date (D/M/Y): Gender: male☐ female☐ other☐

Grade entering in September 2018:

Email:

Phone Number:

Street Address:

Postal Code: City/Province:

Manitoba Personal Health Insurance Number (9 digits):

Manitoba Family Health Insurance Number (6 digits):

Shirt Size: Youth XS S M L XL OR Adult XS S M L XL

Dietary Restrictions/Preferences:

Parent/Guardian Information

Name: Phone number:

Name: Phone number:

Indigenous Declaration (Check If Applicable)

First Nations (Status/Non-Status) ☐ Metis ☐

Inuit ☐ Other ☐:______________________

Medical Information

If you have any medical conditions please inform here:

Emergency Contact (different than Parent/Guardian Information)

Name Relationship

Phone number Alternate number:

Approved list of who may pick up the participant

In order to ensure that the proper people retrieve children, we ask that a list of people who are

allowed to pick up the child be filled out. Unless prior arrangements have been made, the child

will not be released to anyone who is not on this list. Identification may be required for those

picking up the child. Please note that this list can be changed at any time please see staff to

change your pick-up list.)

Name: Name:

Name: Name:

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Photo Release/Consent

I, the parent/guardian of ________________________ hereby authorize the Wii Chiiwaakanak

Learning Centre of the University of Winnipeg and Actua, the national organization of which

Wii Chiwaakanak Learning Centre is a network member, to photograph, audio record, video

record, podcast and/or webcast the child (digitally or otherwise) without charge; and to allow

Wii Chiiwaakanak Learning Centre and Actua to copy, modify and distribute in print and online,

those images that include your child in whatever appropriate way either Wii Chiiwaakanak

Learning Centre and/or Actua sees fit, without having to seek further approval.

☐ I give my consent for the purposes as noted above

☐ I DO NOT give my consent for the purposes as noted above

Print Name

SIGNATURE

Description of Risk, Lease of Liability, Wavier of Claims

In consideration of the Wii Chiiwaakanak Learning Centre of the University of Winnipeg

permitting my child/ward to participate in camp and programs offered by the University of

Winnipeg, I/we agree to use the facilities and participate in programs in compliance with all

rules, regulations and policies as they may exist and change from time to time and I agree as

follows:

I recognize, acknowledge, and am aware that participation in the program carries risk of

personal injury.

I understand that my child/ward will partake in a number of outdoor/indoor activities.

My child/ward is prepared to take part in these activities.

I hereby release and discharge the University of Winnipeg and Wii Chiiwaakanak Learning

Centre, its officers, agents employees, volunteers, sponsors (including particularly Actua) and

their respective heirs, executors, administrators, successors or assigns (collectively known as

the “Releasees”) from any and all claims, demands, damages, costs, expenses, actions and

causes of action, whether in law or equity, in respect of death, injury, loss or damage to my

child/ward or to my person or property however caused, arising in any way connected with my

child’s/ward’s participation in the program. I further hereby undertake to hold and save

harmless and agree to indemnify the Releasees from any and all Liability (including legal fees)

incurred by any or all of them arising as a result of, or in any way connected with my (or my

child’s/ward’s) participation in the program.

No acceptance is permitted unless signed below.

Print Name

SIGNATURE

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Behaviour Action Plan (Please read and review the following Behaviour Action plan with your

child prior to starting camp)

We want all children to have a fun, memorable experience at our day camps. On very rare

occasions, some children’s behaviour negatively impacts others. If a child is asked to leave

camp, it will only be after we have contacted the child’s parents to discuss the situation.

Children may be sent home for the day or for the balance of the week.

Mild-Moderate Severe

- Disrespect to Instructors/Camp

Leaders (not listening or obeying rules)

- Disrespect to other camp participants

(bullying, name calling, swearing,

fighting)

- Not participating in camp activities

(using phone during camp activities,

distracting others)

- Any violent act, which harms another

camper

- Discrimination, Degrading comments

or Harassment of others

- Continuing mild-moderate recurring

events

- Stealing

- Vandalism in or outside the building or

equipment

- Running away or leaving camp without

permission

Action:

1-3 warnings will be issued throughout camp,

depending on the severity of their actions.

After 3 warnings the child will not be allowed

to return to camp.

Action:

Parents will be called immediately and child

will be sent home and not able to return.

☐ I have read and understood the behavior action plan.

Print Name

SIGNATURE