Kidtrax ID #:

Membership Code:

Database #:

FOR OFFICE USE ONLY

184 Horton Street London, ON N6B 1K8 Tel: (519) 434-9114 Fax: (519) 434-7306 www.bgclondon.ca

SUMMER CAMP 2019 REGISTRATION Expiry Date:

Home Phone #: e-mail Address:

The following information is necessary for the Boys & Girls Club of London (BGCL) records and statistical information for our funders.

PLEASE PRINT CLEARLY AND USE BLACK INK:

Child's Name:

Address:STREET # AND NAME CITY POSTAL CODE

Sex: Male FemaleFIRST MIDDLE LAST

/Date of Birth: /DAY MONTH YEAR

Age at camp:

School Name: Grade:

PARENT / GUARDIAN #1 PARENT / GUARDIAN #2Name:

Occupation:

Employer:

Work Phone #:

Cell Phone #:

Work Phone #:

Name:

Occupation:

Employer:

Cell Phone #:

One Parent Family Two Parent FamilyFamily Setting: Joint Custody Other Specify:

FIRST NAME LAST NAME RELATIONSHIP TO CHILD HOME PHONE # ALTERNATIVE # (WORK) (CELL)

List anyone who is NOT ALLOWED to pick up your child:

Phone #:Physician:Health Card #:

FIRST NAME LAST NAME RELATIONSHIP TO CHILD HOME PHONE # ALTERNATIVE # (WORK) (CELL)

EMERGENCY CONTACTS: These will be the people who are allowed to pick up your child or who will be called if a parent/ guardian cannot be reach in an emergency. This information MUST be different contacts than Parents/ Guardians.

Will anyone else other than those listed above be picking up you child? If Yes, please fill out the following:

1.NAME AND RELATIONSHIP TO CHILD NAME AND RELATIONSHIP TO CHILD

2.

PLEASE NOTE: Everyone picking up children will be ask to show photo identification. Please ensure that all people picking up your child are aware of this.

I give permission for my child to walk home from this program without being signed out by an approved adult? Yes No

NAME AND RELATIONSHIP TO CHILD

AdvanceSwimming Ability: Beginner Intermediate

Please list any other camper you would like your child grouped with (similar age):

Are there any current issues which involve your child in terms of Court Orders, Custody Issues and/ or Restraining Orders? If yes, please speak to our Camp Director. Yes No

*All children are required to complete a swim test

Sex: Male Female Sex: Male Female

ALLERGIES

Seasonal:

Food:

Drugs:

Insect:

Other:

YesNo

YesNo

YesNo

YesNo

YesNo

Carries Epi-Pen: Carries Ana Kit:Yes No Yes No

Does your child have any dietary concerns? Lactose intolerant Vegetarian Other

Specify:

Other:Does your child have any of the following conditions?

Does your child have any special needs we should know about?

Does your child require more attention than the 1:12 ratio camp offers? Yes Specify:No

If your child requires additional support, please contact the Inclusion Coordinator at 519-434-9114 to ensure availability and set up an intake session to assess your child's needs. A Supplementary Form is also required with registration and each child may register for two weeks maximum allowing opportunities for others. The form is available on website or at registration booth.

Administration of Medication For children that need medication administered during camp, a parent or guardian must: 1. Provide medication in its ORIGINAL CONTAINER to the Camp Coordinator or Camp Director. We will not accept any form of medication that is not properly labeled or packaged, i.e. in a Ziploc bag. 2. Pick up any remaining medication and packaging every Friday. 3. Inform the Coordinator of Epi-pens and Inhalers - child must keep it but the counsellors are to be made aware of its location. 4. Inform the Coordinator of any changes regarding medication as it may affect the child's performance at camp.

Medication Name Dosage Time of Dosage Purpose Instructions on how the child will self administer the medication (i.e. drink or food required)

Yes No

ADHD ODD Bipolar

Please specify:

Please note: We are unable to accommodate special diet requests; if your child has special diet requirements, please provide their lunch.

SPECIAL NEEDS

DIETARY NEEDS

Carries Inhaler: Yes *child must keep on person

Parent / Guardian Signature Date

Payment of Fees Full payment must be received at the time of registration. We accept VISA, MasterCard, Debit, and Cash. Changes of Weeks / Camp & Refund Policy To receive a refund, all changes and cancellations must be submitted in writing at least one week prior to the campers start date & $15 Administration fee will be charged for Cancellations or Changes per child per cancellation notice. Please note: A $25.00 non-refundable Registration Deposit applies per camper for City Subsidy / Ontario Works Clients AUTHORIZATION - Registration will not be processed without a signature below. In registering the child named in this form to attend BGCL Camp, I, the undersigned parent/guardian or other duly authorized party, hereby agree as follows: 1. To permit my child to participate in the full range of BGCL Camp activities and authorize the BGCL Camp Staff, in the event of accident, injury or illness affecting the above named camper to authorize on my behalf all medical and other procedures, including admission to hospital and all other necessary treatment, as he/she may seem essential for the care and well-being of the said camper. Such action is to be taken only when immediate contact with the undersigned cannot be made. 2. I understand that camp activities have an inherent risk factor and that all appropriate precautions will be taken for participant safety. I agree to not hold the Boys & Girls Club of London or any of it's employees responsible in the event of an injury to my child. 3. I understand and agree to the Boys & Girls Club of London's Summer Camp Policies stated above. PLEASE NOTE: Promotional Material: The BGCL reserve the right and permission to publish, reproduce, distribute and /or otherwise use any still or moving photograph, for such purposes and with such frequency as it shall determine in its sole discretion without further compensation or consideration to me and without further authorization by me for, as yet, unnamed video or photographic projects (including promotion, marketing and social media) which shall constitute the sole property of the BGCL. The BGCL shall be released from and against any and all liability resulting from its use of the photos or related to my use of the product.

Relationship to Child

I do not give permission to use my child's photograph

General Waiver: I, the undersigned, the parent/guardian of the above named child do hereby consent to this child's participation in the Boys & Girls Club of London's programs. I acknowledge that participation in these programs involves light to vigorous activity and includes the possibility of injury. I grant program officials the authority to obtain emergency medical treatment as necessary to ensure that the above named child is safe from further injury. I am aware of no physical or other reasons why this child should not participate in club programs and related club functions. The risk of sustaining injuries results from the nature of the activity and can occur without any fault of either the Member, or the Club, its employees/agents or the facility where the activity is taking place. By choosing to take part in this activity, I am accepting the risk that my child may be injured. The Boys and Girls Club of London does not provide accidental death, disability, dismemberment or medical expense insurance on behalf of the participants in this activity. In consideration of the Boys & Girls Club of London allowing this child to participate in club programs, I agree to waive and release Boys & Girls Club of London, its employees, volunteers, directors and agents (the “Releasees”) from all claims for damages, injury or loss that may arise as a result of my child's participation in programs, including those arising from the Releasees own negligence (i.e a failure to take reasonable care). I will impress upon the child the importance of following club rules, regulations and instructors directions.

SUMMER CAMP POLICIES Age Policy The camper's age the week they are attending camp is their registered age. Children with Difficult Behaviour at Camp Parents will receive a Behaviour Management Form, signed by Camp Coordinators and Management, to assist their child in dealing with any difficult behaviour experienced at camp. If your child needs to leave camp for not correcting inappropriate behaviour, a refund will not be issued. Head Lice If lice is detected on any participant, we will notify parents. Child must be picked up by an authorized person immediately. Sun Screen It is our policy to allow staff to assist participants with the application of sun screen provided the following has been completed. I give permission for the staff of the BGCL Camp to assist in the application of sun screen to my child. I also understand that I must provide a clearly labelled bottle of approved sun screen. We recommend that sun screen be waterproof, provide UVA/UVB protection and have a SPF of at least 30 and that it contain no peanut products.

Yes No

Deposit Amount $ Paid by: Cash DebitVisa Receipt #MC

Amount Paid for Memb $ Paid by: Cash DebitVisa Receipt #MC

Staff

Staff

Amount Owing Amount Paid Receipt# Date Paid Staff Int. CAMPS PAID & WEEK

MC Paid by: Cash DebitVisa Cancellation

Week#

MC Paid by: Cash DebitVisa Cancellation

Week#

MC Paid by: Cash DebitVisa Cancellation

Week#

COST: $210 Members / $220 Non-Members Lunch and snacks included Week 1 & 6 (4 days) Regular Camp $175 Members / $185 Non-Members

Specialty Camps $190 Members / $200 Non-Members

FOR OFFICE USE ONLY

CAMP INFORMATION

Specialty Camp Cost: $225 Members / $235 Non-Members Lunch and snacks included

Games Camp Adventures (Ages 6-12) $225/$235

Wk 1 Jul 2 - 5

Wk 2 Jul 8 - 12

Wk 3 Jul 15 - 19

Wk 4 Jul 22 - 26

Wk 5 Jul 29-Aug 2

Wk 6 Aug 6 - 9

Wk 7 Aug 12 - 16

Wk 8 Aug 19 - 23

Wk 9 Aug 26 - 30

Early Drop Off $3/day or $15/wk (7:30-8:00am)

Late Pick Up $3/day or $15/wk (5:00-5:30pm)

All Stars - (Ages 6-12)

Art & Music (Ages 4-7) $225/$235

Camp-A-Saurus - (Ages 4-6)

Camp Robotech (Ages 6-12) $225/$235

Interactive Arcade (Ages 7-12) $215/$225

iPlay (Ages 4-6)

Just for Girls (Ages 8-12)

Kamp I Direct (Ages 6-12)

Master Chef Junior (Ages 8-14) $215/$225

Outdoor Adventure (Ages 6-12)

STEAM Ahead! (Ages 7-14) $225/$235

Splashworks (Ages 9-15)

Youth B.L.A.S.T. (Ages 11-15)

Snack Attack! (Ages 6-12) $225/$235

Games Camp Adventures (Ages 6-12) $225/$235