Please complete one form for per camper.
The entire form must be completed and accompanied by a 10% deposit to secure space.
CAMPER INFORMATION
NAME
BIRTHDATE
GENDER:
CABIN MATE REQUEST
RKY makes every effort to accommodate one written mutual cabin mate requests of campers who are the same age, gender, and registered in the same program. We ask that you only list
one request. Requests are NOT guaranteed, as has been RKY camp policy. Any questions or special requests should be made directly to the Camp Director. RKY Camp encourages all children
to work together and build new lasting friendships. We advise parents and campers to reference the YMCA Quality 8 when thinking about cabin mate requests.
FEES AND 2015 PROGRAMS
TRADITIONAL CAMPING PROGRAMS
Base Fee
Youth Camp 1 week (Age 7 – 11), as of Dec 31st,
Leaders – In – Training (Ages 15 – 16), as of Dec 31st, 2015




2015




June 28th – 3rd
July 5th – 10th
July 12th – 17th
July 19th – 24th



2nd
Base Fee
LEADERSHIP PROGRAMS
7th
August
–
August 9th – 14th
August 16th – 21st
June 28th – July 10th
July 12th – July 24th
August 2nd – August 14th
August 16th – August 28th
$620.00
$1450.00
The RKY Camp Games (1 week only)
Counsellor in Training Program (Age 16 – 17), as of Dec
(Age 9 – 15), as of Dec 31st, 2015

August 23rd – 28th
Come for a special week at RKY CAMP and join the
Lumbermen or Voyageur team to play the 3 day RKY
Camp Games!
31st, 2015

June 28th – July 24th

August 2nd – August 28th
$620.00
Two Week Youth Camp (Ages 8 – 12), as of Dec
31st, 2015




June 28th – July 10th
July 12th – July 24th
August 2nd – August 14th
August 16th – August 28th
SUMMER DUKE OF EDINBURGH TRIPS
Silver Preliminary, Practice and Qualifying Journey
& Gold Practice and Qualifying Journey (Ages 15+), as
$1200.00
Senior Camp (Ages 13 – 15), as of Dec 31st, 2015




June 28th – July 10th
July 12th – July 24th
August 2nd – August 14th
August 16th – August 28th
$2100.00
Base Fee
of Dec 31st, 2015

July 5th – July 10th

August 9th – August 14th
$720.00
RKY CAMP CAMPERSHIP DONATION
Please consider making a donation to help send a child to camp. All
donations over $20 will be receipted for tax purposes.
$1300.00
Please circle one:
$10
$25
$50
$100
Other: $__________
PAYMENT METHOD
PAYMENT CALCULATION
CHOOSE ONE
Pay in full by credit card
Camp Fee
Sibling Discount (-$50.00 for each additional child –
discount not applied to first child)
13% HST
Tuck Shop Payment (HST already included)
Tuck Payments not accepted at Drop Off
Pay in full by cheque or cash
10% deposit and monthly post dated cheques
10% deposit and monthly credit card withdrawl
10% deposit and full amount due May 1st, 2015
Total Fee
Online Registration (If you wish to input your credit card information
this a great option. (www.rkycamp.org)
Other (please detail)
___________________________________________________
_____________________________________________
10% Deposit (must be included at time of registration)
Important Dates and Information
ALL PAYMENTS AND PAYMENT PLAN ARRANGEMERTS MUST BE RECEIVED IN FULL BY MAY 1st, 2015.
ALL FEES MUST BE PAID BY THE FIRST DAY OF THE ENROLLED SESSION.
CAMPER INTRODUCTION AND EXPERIENCE
Personal Information
Name of Camper: _____________________________________ Birth date: _____ / _______ / ___________
dd
mm
yyyy
Session: ____________________________________ Cabin Mate Request: ____________________________
Experience and Outlook
Years at RKY _______________________
Experience at Other Camps_________________________
What is your child’s outlook on Camp this summer? _______________________________________________
Habits & Home Life
Do you expect your child to be homesick? _____________________
If so what might help cheer them up? _____________________________
Does your child make friends easily? _________________________________
Please describe your child’s eating habits? ___________________________
What is your child’s normal bedtime? ___________________________________
Are they a bed wetter? ______________________________________________________________________________________
Are there any other particular considerations that we should be aware of? _____________________________________________
Have there been any significant family changes in the last year? _____________________________________________________
Program
What is your child most looking forward to at camp this summer?
________________________________________________
What are they most nervous about? ____________________________________________________________________________
What are your child’s hobbies and interests? _____________________________________________________________________
Other
Has your camper menstruated? Y / N
If no, do they know about menstruation? Y / N
Are there any special circumstances or other considerations that we should know about to make your child’s stay at RKY more
enjoyable?
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
____________________________________________________________________________________________________
Tuck Shop Information
The 2015 Tuck shop will provide a mix of healthy snacks, treats and camp merchandise.
All camp fees INCLUDE a non refundable Tuck surcharge of $17.50 based on two week program (8.75 for one week, $35.00 for a month). This will
ensure that all campers have some money available to them to purchase snacks/treats/small merchandise items while at camp. (Campers receive
tuck every second day at camp and are allowed to spend a maximum of $2.50 on food purchases.)
If your child will be purchasing merchandise (t-shirts/sweatshirts/hats) at camp a separate Tuck Account will be established. To add money to your
child’s Tuck Account for merchandise you can:
1. Do this when you complete your initial registration – this can be done online, in person, or over the phone.
2. Call the Winter Office: 613-546-2647, ext. 235.
Any money added to your child’s Tuck Account (for merchandise) prior to the first day of camp will be available to them ON THE FIRST DAY. Any
money added to your child’s tuck account (for merchandise) once the camp session has started will be available to them by the 4th day of the
session.
We will NO LONGER BE ACCEPTING TUCK MONEY AT THE DROP OFF.
Refunds will only be available for monies left in Tuck Accounts established for purchasing merchandise. Refunds must be requested on your child’s
registration form. Where no selection is made on the registration form, or where no forms are returned any remaining monies will be donated to
the RKY Campership Fund.
Donate Leftover Tuck Monies
Refund Leftover Tuck Monies
RKY CAMPER HEALTH INFORMATION 2015
Camper’s Name:
Ontario Health Card #:
Issue Date:
Expiry Date:
PRIMARY CONTACT
EMERGENCY CONTACT #1
Name
Last:
Address:
City:
Name
First:
Apt #
Province:
Postal Code:
Home Phone:
Business:
Cell Phone:
Email:
Last:
Home Phone:
Please check box if you would like to receive emails. Much information
through the year is transmitted through email
I consent to receive information via email from RKY Camp. You may
unsubscribe at any time by responding to any emails with an unsubscribe
request. Your email is strictly for RKY Camp purposes and will not be shared
in any way.
First:
Cell Phone :
Business Phone:
Relationship to Camper:
EMERGENCY CONTACT #2
Name
Last:

Health Insurance Provider & Policy #:
Birth date:
First:
Home Phone:
Cell Phone :
Business Phone:
Relationship to Camper:
HEALTH HISTORY AND PERSONAL INFORMATION
Are your child’s immunizations up to date?

Yes
No (Details): ____________________
History of Communicable Diseases and Heath Issues (Please Describe)

Asthma ____________________

Diabetes ____________________

Hay Fever ____________________

Skin Conditions ____________________

Hepatitis ____________________

Chicken Pox ____________________

Mumps ____________________

Behavior Issues ____________________

Is your child on a medical vacation while at camp? Y / N

Epilepsy ____________________

Fainting ____________________

Heart Condition ____________________

Frequent Colds ____________________

Other ______________________________________
Dietary Needs:
 Vegetarian Lactose Intolerant Gluten Free Other
Please provide any additional required details:
__________________________________________________________
Allergies : Please describe any allergies that your camper has, including
type of reaction and regular treatment: __________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Camp medical staff are able to provide over the counter medications for
common ailments. Drugs provided can include acetaminophen,
ibuprofen, cold medication, Gravol, etc… Please indicate any drugs that
you do not wish us to provide if needed.
___________________________________________________________
___________________________________________________________
Please indicate any required medications while at camp and dosage
___________________________________________________________
___________________________________________________________
___________________________________________________________
______________________________________________________
All medication must be in current, original packaging in the name of
the camper, and outline the accurate dosage.
Please contact the office directly with any other pertinent medical
information we may require.
RKY CAMP 2015 – AUTHORIZATION, ASSUMPTION, RELEASE AND INDEMNITY
Page 1
Registration and Cancellation Policy
I, the undersigned custodial parent/guardian of the participant, understand and agree to the following RKY Camp policies:
-
-
-
Participation in all RKY Camp programs is allocated on a first-come first-serve basis.
All RKY Camp fees are subject to 13% HST.
Incomplete applications will not be processed.
A 10% non-refundable deposit is required to hold the registration for the participant.
All subsidy applications require a minimum $25.00 deposit at the time of registration.
Returned cheques or payments that are unable to be processed will be assessed a fee of $25.00 for return.
All fees, unless otherwise arranged with the RKY Camp registrar or director are due May 1st, 2015. Participants failing to provide full payment may lose their
spot.
Cancellations on or after May 1st, 2015 will be allowable for medical reasons only. To qualify for a full refund (less any administrative fees) a Medical Certificate
(i.e. doctor’s note) must accompany written notice of cancellation. No refund of any amount will be granted for non-medical cancellations received on or after
May 1st, 2015.
Refunds will not be issued where a participant is removed from the RKY Camp program for any of the following reasons: at the choice or request of the
participant or the participant’s custodial parent/guardian, due to behavioral issues, or due to medical reasons.
RKY Camp reserves the right to cancel registration if the participant’s medical information is not completed and if signed authorization is not returned to the RKY
Camp Office prior to the commencement of the camp session.
RKY Camp reserves the right to cancel programs two weeks prior to their start date due to poor registration numbers. In the event of a cancellation due to poor
registration numbers, full refunds will be provided for each participant.
All cancellations and withdrawals from the RKY Camp must be made in writing to the RKY Camp Office.
Loss/Theft and Vandalism
RKY Camp is not responsible for lost, stolen or misplaced belongings of any kind. All valuables and belongings are brought to RKY Camp at the risk of the participant. RKY
Camp reserves the right to charge any user of our site should equipment be intentionally broken, vandalized, or destroyed.
Removal from Camp Program
I, the undersigned custodial parent/guardian of the participant, understand and agree that intentional behavior by a participant that puts the
participant or others at physical or emotional risk may result in immediate dismissal from the RKY Camp program. In addition, possession of alcohol,
tobacco products and/or illegal or harmful substances will result in immediate dismissal from the RKY Camp program. Any expenses incurred due to
dismissal from the RKY Camp program will be my sole responsibility. I, or a person I have designated in writing, must be available to pick up my child
should he/she be dismissed from the RKY Camp program or should any emergency arise which requires emergency transportation of my child. I
acknowledge that no refund will be provided to participants leaving camp prior to the end of the session due to disciplinary action.
Media Release and Promotional Materials
I understand that RKY Camp reserves the right to publish, reproduce, distribute and use for promotional purposes any videos, photographs and audio
recordings of all participants enrolled in their programs. These materials shall be used without any compensation and are the property of RKY Camp.
Photos, video and audio clips may appear on but are not limited to RKY Camp print materials, website, social media and other media outlets.
Assumption and Acknowledgement of Risk
I understand that there is some risk involved in the activities offered by the RKY Camp, both on and off the camp property. I have been given the
opportunity to inquire about the safety and behavior standards enforced at RKY Camp. I understand that despite all reasonable precautions being in
place to provide proper organization, supervision, and equipment for all activities, circumstances may arise which are not foreseeable or which are
beyond the control of the RKY Camp. I understand and acknowledge that RKY Camp is not responsible for any damages caused by the delay or failure
to perform or complete any activities or to provide any transportation or accommodation related to the program when the delay or failure is due to
fires, strikes, floods, acts of God, lawful acts of public authorities, or delays or defaults caused by common carriers, which cannot reasonably be
foreseen or provided against.
I acknowledge and assume any and all risks associated with my child’s participation in the program. I wish for my child to participate in the program.
I further acknowledge that I have discussed with my child his/her obligations to follow RKY Camp rules, regulations, policies and procedures so as not
to endanger fellow participants and staff and to ensure the camp experience is enjoyable for all participants. I believe that my child understands
his/her obligations in this respect and the consequences of any misconduct.
RKY CAMP 2015 – AUTHORIZATION, ASSUMPTION, RELEASE AND INDEMNITY
Page 2
Consent and Medical Authorization
By registering my child for the RKY Camp I am providing my consent for him/her to participate in all RKY Camp activities. To the best of my knowledge, my child is in
good health.
I have disclosed all of the necessary information about my child’s needs and abilities on the registration form. I am aware that my child may be removed from the RKY
Camp program if I fail to share the requested information with RKY Camp. I grant permission for RKY Camp to share information about my child and family with
program partners and other community agencies as necessary. Participation in the RKY Camp requires that every participant has health insurance coverage. I
acknowledge that I have obtained adequate health insurance coverage for my child. I will inform RKY Camp of any changes in my child’s health. I certify that my child
meets the required age, and is emotionally and physically capable of participating in the activities for which he/she is registered. I will notify RKY Camp if my child is
exposed to an infectious disease during the three weeks prior to arriving at camp.
I authorize RKY Camp wellness staff to administer my child any required medication as outlined in this information package. In case of emergency I grant RKY Camp staff
authority to act on my behalf. In case of surgical emergency, and I am not immediately available for consultation, I hereby give permission to the physician, selected by
the Camp Director, to hospitalize, secure proper treatment for and to order injections, anesthesia, or surgery for my child, if deemed necessary.
I am the custodial parent and/or legal guardian of my child.
There is a custodial order/arrangement in place for the custody of my child (please circle):
Yes
No
If there is a custodial order/arrangement in place for the custody of my child, I acknowledge that I am required to provide the custodial order/arrangement to RKY Camp
staff prior to the commencement of the RKY Camp program. I acknowledge that my child may not be permitted to attend camp without this.
Release, Indemnity, and Waiver
In exchange for RKY Camp permitting my child to participate in the program, I hereby release and indemnify RKY Camp, including its respective officers, directors,
employees, volunteers and agents, and their successors and assigns, from any and all claims arising from, connected with, or in preparation for, participation in RKY
Camp programs or activities, including for personal injury and property damage sustained in consequence of loss, injury or damage to me or my child, howsoever
caused, including any and all claims in tort, negligence or breach of contract.
Furthermore, I waive any and all rights to participating in a class action lawsuit against RKY Camp.
Any claims and/or lawsuits against RKY Camp, including its directors, staff, volunteers, agents or assigns, shall take place under the exclusive jurisdiction of the laws and
regulations of Ontario, and the applicable law to be applied to any dispute shall be the laws of Ontario.
In order to ensure the safety and well-being of all participants, I acknowledge that RKY Camp reserves the right to alter the program at any time without compensation
to participants, parents or guardians. I agree to assume any expense(s) arising from program dismissal.
I confirm that all legal guardians have read and are in agreement with the above AUTHORIZATION, ASSUMPTION, RELEASE AND INDEMNITY and that all legal guardians
have read and agree to abide by RKY Camp’s terms and conditions. As the custodial parent and/or legal guardian, I have the authority to sign on behalf of my child.
In signing this AUTHORIZATION, ASSUMPTION, RELEASE AND INDEMNITY, I consent to my child, _______________________________, participating in the RKY Camp.
(PRINT CHILD'S NAME)
_____________________________________
Signature of Custodial Parent/Guardian
_____________________________________
Printed Name of Custodial Parent/Guardian
________________
Date