Camp Optimiste de Crysler – summer 2015
Registration Form
Please complete one form per child in block letters
NAME: ___________________________________________________________________________________
FIRST
LAST
ADDRESS:___________________________________________________________________________________________
NO.
STREET
CITY
DATE OF BIRTH: ______________________________
POSTAL CODE
AGE: _________
SEX: ______________
DAY / MONTH / YEAR
HEALTH INSURANCE CARD NUMBER: _____________________________________ EXP. DATE: ___________
PREFERED LANGUAGE(S) OF SERVICE: ☐English
☐French
☐Both
For the planning and health and safety reasons, please answer the following questions:
ALLERGIE(S): ____________________________________________________________________________
MEDICATION TO BE TAKEN: ________________________________________________________________
OTHER MEDICAL CONDITION: ______________________________________________________________________
MY CHILD MAY LEAVE THE CAMP: ON HIS OWN: ___________ WITH A PARENT ONLY: _______________
WITH THE FOLLOWING INDIVIDUAL(S): _______________________________________________________
Parent / Guardian Information
PARENT 1: ________________________________________________________________________________
FIRST
HOME: (
)
-
LAST
WORK: (
)
-
CELL PHONE: (
)
- _____
EMAIL ADDRESS: ___________________________________________________________________________
☐ check here if you do not want to be added to the email distribution list
PARENT 2: ________________________________________________________________________________
FIRST
HOME: (
)
-
LAST
WORK: (
)
-
CELL PHONE: (
)
- ______
EMAIL ADDRESS: ___________________________________________________________________________
☐ check here if you do not want to be added to the email distribution list
Other Emergency Contact
1st CONTACT: ______________________________________________________________________________
FIRST
RELATION WITH CHILD: _____________________________
LAST
PHONE NUMBER: (
)
- _________
2nd CONTACT: ______________________________________________________________________________
FIRST
LAST
RELATION WITH CHILD: _____________________________ PHONE NUMBER: (
)
- _________
Please return this form along with payment (cash or cheque) to the Centre de santé communautaire de
l’Estrie (Attention François Séguin), 1 Nation Street, Crysler, Ontario K0A 1R0. Cheques are payable to the
Crysler Optimist Club. For further information: 613-987-26853 #228
Summer Camp, Week Selection (8 a.m.-5:30 p.m.) – $125/Week
Additional Morning Hours (6 a.m.-8 a.m.) – $15/Week
Day pass (6 a.m.-5:30 p.m.) – 30$/Day
Please check the applicable box(es):
☐ Week 1 World Adventure (June 29-July 3)**
☐ Week 2 Outrageous Sports (July 6-10)
☐ Week 3 Rockstars (July 13-17)
☐ Week 4 Christmas in July (July 20-24)
☐ Week 5 Crazy Science (July 27-31)
☐ Week 6**Dinosaurs & Disney (August 3-7)
☐ Week 7 Master Chef Crysler (August 10-14)
☐ Week 8 Survivor Week (August 17-21)
☐ Week 9 Mystery Week (August 24-28)
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☐
☐
☐
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☐
☐
☐
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Week 1 Morning hours (6-8am)
Week 2 Morning hours (6-8am)
Week 3 Morning hours (6-8am)
Week 4 Morning hours (6-8am)
Week 5 Morning hours (6-8am)
Week 6 Morning hours (6-8am)
Week 7 Morning hours (6-8am)
Week 8 Morning hours (6-8am)
Week 9 Morning hours (6-8am)
st
☐ Week 1 Day pass_________________
☐ Week 2 Day pass_________________
☐ Week 3 Day pass ________________
☐ Week 4 Day pass_________________
☐ Week 5 Day pass_________________
☐ Week 6 Day pass_________________
☐ Week 7 Day pass__________________
☐ Week 8 Day pass_________________
☐ Week 9 Day pass_________________
rd
**Note that the camp will be closed on Wednesday July 1 and Monday August 3 , 2015.
General conditions
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All fees must be paid upon registration.
Registration is on a first-come, first-served basis.
Cheques must be made to the Crysler Optimist Club.
Cheques must be post-dated 7 days before your child begins camp
In case of cancellation, a $25.00 fee per registration will be retained. In order to receive a refund, you must inform
th
us by June 10 2015. No refunds will be issued after this date.
In case of change of week, a $25.00 fee will be required.
If a cheque is returned as insufficient funds, the child will be removed from the camp until such time as payment is
made in cash.
The Crysler Optimist Camp has the right to change the programming without notice.
It is a privilege to participate in summer camp. The Crysler Optimist Camp has the right to suspend a child from
camp activities if it is deemed necessary.
☐ I accept that my child may be photographed or filmed. This authorisation is valid at all times during camp. I
acknowledge that these pictures or videos may be used for but not limited to flyers, promotional material, Website by the
Crysler Optimist Camp, the Centre de santé communautaire de l’Estrie and the Crysler Optimist Club. ☐ I refuse
I, ___________________________ consent to my child’s participation in the Crysler Optimist Summer Camp.
Name Parent/Guardian
I agree to waive and release the Crysler Optimist Camp, the Crysler Optimist Club, the Centre de santé communautaire de
l’Estrie and their employees, volunteers and organisers from all claims for damages, injury or loss, including death, that may
arise as a result of my child’s participation in the camp.
SIGNATURE: _________________________________
DATE: _________________________
For internal use only
Number of weeks: ______________________ Additional morning hours: _______________________
Amount Paid: $ ________________________
Payment type: ________________________