Camper Application: Specialty Camp (9-14)
Camp you are attending:
Camper/Participant:
Registration Fees $100.00/week
Name
Age
Gender _______ Grade _________
□
Skateboard Camp
July 6th-10th, 2015
□
Bike Camp
July 13th-17th, 2015
□
Wild Roots
July 20th-24th, 2015
□
Scooter Camp
July 27th-31st, 2015
□
Skateboard Camp
August 4th-7th, 2015
□
Film Camp
August 10th-14th, 2015
□
Wild Roots
August 17th-21st, 2015
□
Mystery Camp
August 24th-28th, 2015
School _______________________________________
Date of Birth (MM/DD/YR) ________________________
Street
City
Province:
Postal Code:
Provincial Health Card number:____________________
Expiry:________________________________________
Guardian(s): Contact Information:
Guardian 1 Name: ________________________________
Home Telephone (
)
______
Business Telephone (
)
Cellular Telephone (
)_________________________
Email: ________________________________________
Relationship:
Day Camp Hours Info:
Guardian 2 Name: ________________________________
Home Telephone (
)
______
Business Telephone (
)
Cellular Telephone (
)_________________________
Email: ________________________________________
Relationship:
Lunch Program:
Please list any allergies, relevant medical information or special
needs your child has:
______________________________________________
Per Day Fee:
___________________________________
___________________________________
________________
Drop off for our day camps are between 8:00am and 8:30am
and pick up will be between 4:30pm and 5:00pm.
This summer we are offering a healthy lunch program for
our campers. The cost is $3 per day. If you would like your
child to participate in this program, please fill out a lunch
order form
If your child plans on attending camp on a per day basis, it is
$25 per day and $15 per day on Fridays. Please check the
days you plan on attending camp if you are only coming
selective days:
Mon:___ Tues:___ Wed:___ Thurs:___ Fri:___
Total:______
Emergency Contact Information:
Please provide the name and phone number of a person who may be contacted in an emergency, in the event that staff are
unable to reach a parent or guardian.
Emergency contact: __________________________Phone: _________________
Family Doctor’s Name_______________________ Phone: __________________
Please provide the names and relation of individuals that have permission to pick up your child.
Name: _______________ Relation:________________,
Name: _______________ Relation:________________,
Name: _______________ Relation:________________, Name: _______________ Relation:________________,
Parent/ Guardian Signature: _______________________ Date: ____________
Kentville Parks and Recreation Fee Structure:
Kentville Parks and Recreation would like to provide much needed financial support for children and families who are unable to
afford the full cost of participation in our programs. Kentville Parks and Recreation has a voluntary tiered registration fee, meaning
families can choose the amount they feel they are able to pay for their camper. Please select a level that is reasonable for your
family:
□ $125
□ $100
□ $75
□ I am unable to pay any of these amounts and wish to speak to someone about my options.
Payment Type:
I wish to pay the amount indicated above using the following method:
□
Cheque
□
Cash
Please make cheques payable to Town of Kentville.
I live in the Town of Kentville □
I live outside the Town of Kentville □
TERMS AND CONDITIONS
Registration is not complete unless payment is made in full, or a post-dated cheque has been received and the registration form completed and the
waiver form signed. The Town applies a charge of $20.00 to any cheques returned NSF.
To secure a spot for any Camp session payments a post dated cheque may be used, however cheques must be post dated for the Monday of the week
prior to the session being booked. Each child and must be registered and paid for on the first day of each week.
Waiver
I am aware that the staff and the Town of Kentville are responsible for my child/children upon his/her/their entrance to day camp. I understand that
the Town assumes no responsibility or liability for loss suffered by my child. The Town of Kentville also has the right to remove my child from camp if
my child has proven to be a hindrance to the successful operation of day camps as a result of medical condition, disciplinary problems etc. If my child
is removed from camp for disciplinary reasons no refund will be issued for any days missed.
Refund Policy
There will be an administration fee of $10.00 for each cancellation and/or refund processed by the Town of Kentville. Refunds will only be provided if
a child has taken part in 2.5 days or less in any given camp for reasons unforeseeable and unplanned. In such cases, up to half the registration fee
minus the $10.00 administration fee may be refunded. Refunds must be requested through the Kentville Parks and Recreation Department and take
7-14 days to be processed. Refunds will only be issued to persons named on the registration form, and will be given in the form of a cheque.
I _______________________ have read and understand the above “waiver” and “refund policy” sections of this contract and agree to the terms
stated within each.
______________________________
Signature
________________
Date
I give permission for my child’s picture to be taken and that photos of my child participating in Kentville Recreational Programs may be used in the
future for promotional materials. Yes ___
No___
Please sign______________________