Summer Day Camp Registration Form

Participant Information

Child Name(*)

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Date of Birth(*)

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Grade(*)

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Age(*)

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Home Phone(*)

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Home Address(*)

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Physician Name(*)

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Physician Contact Number(*)

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Medical Conditions:

Please list any medical conditions or allergies that BAP staff should be aware of, and any medications that may be required during the program. Please enter N/A if there are no medical issues for child. If your child requires medication administration, there will be an additional medication administration form required.

Medical Conditions(*)

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Parent/Guardian Contact Information:

First Parent/Guardian Name(*)

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First Parent/Guardian Work Phone

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First Parent/Guardian Cell/Home Phone(*)

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Second Parent/Guardian Name

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Second Parent/Guardian Work Phone

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Second Parent/Guardian Cell/Home Phone

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First Parent/Guardian Email

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Second Parent/Guardian Email Address

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Emergency Contact Information

An emergency contact must be an additional individual outside of a parent/guardian. The emergency contact will only be contacted in the event of an emergency when parent/guardian 1 & 2 cannot be reached.

Emergency Contact Name(*)

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Relationship to Child(*)

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Emergency Contact Work Phone

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Emergency Contact Cell or Home Phone(*)

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Child Pick Up Information

Please List all parties that have permission to pick up child at the Summer Day Camp program (please include parent(s) and any other individuals that will be picked up your child)(*)

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Parent/Guardian Signature

I hereby give permission to the above mentioned youth to participate in the Municipality of the District of St. Mary’s Summer Day Camp Program located in the Kids First room at St. Mary’s Education Centre Academy.

Parent/Guardian Signature(*)

Sign Above

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Signature Date(*)

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Permission to Leave Property

Activities for the Summer Day Camp Program will take place frequently at the following locations. Please check off each location to give permission for staff to take your child to this location.(*)

Stonewall ParkSMECA PlaygroundSMECA Soccer Field/Outdoor ClassroomSt. Mary's Recplex Invalid Input

Permission for Walking Home

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Waiver

PLEASE READ BEFORE SIGNING

I, the parent/guardian of the above listed participant hereby give my approval for that child to participate in any and all activities pertaining to the Summer Day Camp Program.

I, THE UNDERSIGNED, RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE MUNICIPALITY OF THE DISTRICT OF ST. MARY’S, ITS STAFF, VOLUNTEERS, AND SPONSORS FROM ALL CLAIMS ARISING FROM ANY LOSS OR INJURY SUFFERED BY THE ABOVE NAMED PARTICIPANT WHILE INVOLVED IN THE SUMMER DAY CAMP PROGRAM.

Please indicate name of parent guardian signing waiver(*)

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I, the above listed, have read and understand the above waiver.

Waiver signature(*)

Sign Above

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Today's Date

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Security check(*)

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Participant Information

Medical Conditions:

Parent/Guardian Contact Information:

Emergency Contact Information

Child Pick Up Information

Parent/Guardian Signature

Permission to Leave Property

Waiver

PLEASE READ BEFORE SIGNING

Residents