Township of Brock Summer Day Camp 2015 Registration Form Camp Hours: 8:30-4:30 Monday- Friday *Ages 4-12 as of July 1, 2015 CHILD’S INFORMATION First Name:___________________________ Birthdate:(mm/dd/yyyy):________________ Last Name:_________________________ Age as of July 1 2015:________ Gender: M F PARENT/GUARDIAN ONE: Name:__________________________ Email:_________________________________ Phone #:____________________ Address:________________________ City: _______________ Postal:_____________ Cell #: ______________________ PARENT/GUARDIAN TWO: Name: __________________________ Email:_________________________________ Phone #:____________________ Address:________________________ City: _______________ Postal:______________ Cell #:______________________ ALTERNATE EMERGENCY CONTACT: Name:_____________________________ Relation:______________________ Phone Number:_____________________ Name:_____________________________ Relation:______________________ Phone Number:_____________________ CAMP SESSION: Please check the sessions and locations you would like to register for. Day Trips are included in the registration fee. Sunderland 1 2 3 4 5 6 7 Cannington 1 2 3 4 5 6 7 Beaverton 1 2 3 4 5 6 7 Session Dates Super Early Bird Early Bird before June 1 Regular Price $90 $100 8 8 8 Camps run at the Arena Community Centres in each location. Themes (Tues, Thurs, Fri) Trips (Wednesdays) *Wed & Thurs – short weeks before May 1 1 2 June 29, 30 July 2, 3 July 6-10 $80 $100 $110 $120 3 July 13-17 $100 $110 $120 4 July 20-24 $100 $110 $120 5 July 27-31 $100 $110 $120 6 7 August 4-7 August 10-14 $80 $100 $90 $110 $100 $120 8 August 17-21 $100 $110 $120 Canadian Pride, Hawaiian Hullabaloo Space is the Place, Survivor, Groovy Hippies Valentines, Dirt don’t hurt, Mighty Jungle Monsters Vs. Aliens, Wild West, Red Carpet Disco Fever, Disney, Christmas in July Easter, Pirate Party Halloween, Olympics, Mexican Fiesta Safari Adventure, Amazing Race, Dino Doom Cedar Water Park *Trip on Tuesday Roxy Theatre/ Splash Pad Bowmanville Zoo Roller Skating Place Putting Edge Neb’s Fun World Elmvale Zoo Rounds Ranch Payment in full is required before May 1st for Super Early Bird Price and June 1st for Early Bird Price. Please forward cheque for full amount payable to the Township of Brock. Sessions with insufficient registration will be cancelled one week in advance. A full refund will be issued if your child cannot be transferred to another session. Total Fee:__________________ Cash: Cheque: Any questions regarding Summer Day Camp please contact Alicia Bagshaw, Recreation and Leisure Coordinator. abagshaw@townshipofbrock.ca / 705-432-2355 ext. 243 Completed forms should be sent to the Township of Brock Municipal Office TOWNSHIP OF BROCK, 1 CAMERON ST. E., P.O. BOX 10, CANNINGTON, ON L0E 1E0 (705)-432-2355 MEDICAL INFORMATION: Please indicate if the camper experiences or has experienced any of the following condition(s): Severe Allergies ADD/ADHD Physical Limitations Other Special Needs Specify medical or special need: __________________________________________________________________________________________________ __________________________________________________________________________________________________ Is medication required to be taken at camp? Yes No If yes, Please give procedure and time of day_______________________________________________ I understand it is the child’s responsibility to look after and administer their own medication while at camp unless they are not physically able. I give the Township of Brock permission to administer the medication in cases of emergency. Parent Signature:_____________________________________Date:_____________________________________ PICK UP DROP OFF: In the event that I/We are not able to pick up my/our child, he/she has my/our permission to leave with the following individual(s): Name:_____________________ Relation:________________ Name:_____________________ Relation:_________________ WALK HOME: I, __________________, give permission for my child, __________________, to walk home at the end of camp at 4:30. MEDIA CONSENT: Township of Brock Summer Day Camp would like to promote the activities that the children participate in for future participants in camp. In order to do this we require your consent for your child’s picture to be used in this promotional material (brochures, newspapers, slide shows etc.) I, _____________________, give permission for my child, ______________________, to have his/her picture taken and used for advertising purposes by The Township of Brock Summer Day Camp. Parent/Guardian Signature: ____________________________ Date:____________________ Informed Consent Release and Waiver of Liability Indemnity Agreement. This form must be read and signed for your child to participate. ELEMENT OF RISK This activity/program may present various elements of risk. Accidents resulting from such activities may occur and cause injury. These accidents result from the nature of the activity and can occur without any fault on either the part of the Township of Brock or its employees or agents. By choosing to allow your child to participate in the Summer Day Camp, you are assuming the risk of an accident occurring. ACKNOWLEDGEMENT I, __________________________________________, understand and accept the above and provide the Township of Brock, its employees or agents with the following waiver of liability and indemnification agreement. RELEASE AND INDEMNIFICATION AGREEMENT I, __________________________________________, hereby release the Township of Brock and its staff and agents from any and all liability for any injury sustained by my child, regardless of how caused, resulting from my child’s participation in the Summer Day Camp arranged through the Township of Brock. I further agree to indemnify and save harmless the Township of Brock and its staff and agents from any and all suits, demands, torts, and actions of any kind which may be brought against its staff or agents for which it/they may become liable by reason of any injury, loss, damage or death resulting from, or occasioned to, or suffered by any person or any property, by reason of any act, neglect or default of my child. I HAVE READ THE ABOVE AND UNDERSTAND THAT I AM ASSUMING THE RISKS ASSOCIATED WITH MY CHILD PARTICIPATING IN THE TOWNSHIP OF BROCK SUMMER DAY CAMP. Parent/Guardian Signature: ______________________________________Date: ___________________________________ TOWNSHIP OF BROCK, 1 CAMERON ST. E., P.O. BOX 10, CANNINGTON, ON L0E 1E0 (705)-432-2355
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