Camper Registration Form
Scott Mission Camp 2015 CAMPER REGISTRATION FORM IMPORTANT (NEW AND RETURNING APPLICANTS) Please ensure that this application is COMPLETED AND SIGNED BEFORE SUBMISSION. Incomplete or unsigned forms will be returned to sender by mail and delay your child’s registration for camp. REGISTRATION AND MEDICAL FORMS MUST BE SUBMITTED TOGETHER. We cannot hold spaces for applications with missing information. Camper Personal Information Camper Name: Birthdate: (First) (Last) (Month/Day/Year) Address: Apt: City: Postal Code: Health Card Number: Male Camper is: Female (Please include copy of medical insurance coverage if child does not have an OHIP card) How many people live in this household? How many children/dependents in this household? Are there any concerns regarding custody or visitation of this child? (If YES, please explain below) Child’s Swimming Ability (swimming ability will be tested on first day of camp): Beginner Camper is: Taking the bus to and from Toronto pick-up location YES Intermediate NO Advanced Unknown Dropped off and picked up directly at Camp in Caledon by parent Does your child have any emotional or behavioral issues or physical limitations? Please describe the nature of the issue and any related medications or counseling. Use a separate piece of paper if necessary. Parental and Emergency Contact Information Mother/Guardian Name: Home Phone: Work Phone: Cell Phone: Same address as camper? YES Other: NO - If no, then add here: Father/Guardian Name: Home Phone: Work Phone Cell Phone: Same address as camper? YES Other: NO - If no, then add here: EMERGENCY CONTACT – In the event of an emergency where we cannot reach the parent/guardian, campers require an additional emergency contact. Please provide the information of someone you would trust with your child in this situation (family friend, relative, etc.) and who will be available while your child is at camp. Emergency Contact Name: Relationship to Child: Home Phone: Cell Phone: Financial Information This area must be completed in order for us to assign an appropriate camp fee for your child. Please complete this portion using round numbers. Applications cannot be processed without this information. Proof of income may be requested. Wages/EI: Ontario Works/Social Assistance: Transitional Child Tax Benefit: __________ Child Support: O.D.S.P: Other: Ontario Child Tax Benefit: _______ TOTAL INCOME: _________OR INVOICE AGENCY Agency Billing Information: ***The true cost of camp is $650 per child. To apply for a subsidy, please check off the following box: 3852 THE GRANGE SIDEROAD, CALEDON, ONTARIO L7C 0C3 905.838.2713 SCOTTMISSIONCAMP.COM Camp Sessions and Code of Conduct Campers can attend one session per summer. We are unable to make exceptions if your child is not in the right age bracket for your preferred session (see ‘year of birth’ columns beside sessions). Please check your first and second session choices in order of preference. MAIN CAMP SESSIONS Session Dates Year of Birth Session 1 Jun 29- July 4 2001-2007 Session 2 July 6 – 11 2001-2007 Session 3 July 13 - 18 2001-2007 YOUTH CAMP SESSIONS Session Dates Year of Birth Youth Session July 20 - 25 1998-2000 Senior Youth Aug 14 - 16 1995-1998 BUS LOCATION NOTE NEW East Toronto pick-up location for this session (only location) Session 4 July 27 - Aug 1 2001-2007 Session 5 Aug 3 - 8 2001-2007 Session 3 ONLY - NEW LOCATION: 1550 O’Connor Drive, Toronto (near Victoria Park & O’Connor) *This will be the only bus location for this session All Other Sessions: Lord Lansdowne Public School 33 Robert Street, Toronto (behind The Scott Mission near Spadina & College) CAMPER CODE OF CONDUCT - “Making SMC a Safe Place…” We want camp to be a safe and positive experience for all campers. Please read and explain the following ‘camp rules’ to your child. 1. Campers must be willing to listen to and follow the instructions of camp staff at all times. 2. Campers must be respectful of other children at all times. 3. Campers may not wear clothing with inappropriate or offensive language or pictures. 4. In regards to swimwear, all girls must wear one-piece bathing suits or a t-shirt over a two-piece bathing suit. Boys must wear modest, loose fitting shorts – no speedos. 5. Campers are not permitted to leave camp property without a counselor at any time. 7. Campers are expected to follow all safety rules and emergency procedures. 8. Campers should not use other campers or counselors belongings without permission. 9. Campers should not bring articles seen as unnecessary by the camp director (matches, lighters, cell phones, video games, money, etc.) These and other like items will be collected and returned to parents at the end of the camp session. 10. Campers must be willing to participate in all areas of camp program and cooperate with camp staff and other campers. This will ensure a positive and enjoyable camping experience for all. 11. Campers must be under the direct supervision of camp staff at all times. 6. Campers must not enter cabins that are not their own without an invitation. Waiver and Informed Consent Safety is a priority at camp. For insurance reasons, we are obliged to notify parents that sending a child to camp is a risk. We have safety rules and emergency procedures which we expect all campers to follow and will do our utmost to provide a safe environment for campers. I, the undersigned parent/guardian of the above named participant(s), hereby give my consent for the Camp Director and/or designated staff in their full and complete discretion to search the person or belongings of the above named participant(s) while at the Camp or any Camp related outing, for any items that threaten or jeopardize the safety, health and security of the participants or any other participants or staff and volunteers at the camp, including but not limited to drugs, alcohol, cigarettes, materials and weapons of any kind. I understand that should any such items or similar items be discovered in the belongings of the above named participant(s) that the parent/guardian is to be notified that immediate dismissal from the camp will result and authorities may be notified. I hereby fully release and remiss and forever discharge the Camp Director and/or designated staff from any and all claims or liabilities which might otherwise arise from carrying out any search. 1. 2. 3. 4. 5. 6. 7. 8. The Camp Director reserves the right to dismiss a camper who in his/her opinion is a hazard to the safety and rights of others, or appears to have rejected the reasonable controls of camp staff. I have read and understand the terms listed in the Camper Code of Conduct and have explained them to my child. I understand that my child will be transported to the camp in a chartered school bus. I also acknowledge that my child (depending on age and session) will take part in out-trip activities located off the Scott Mission Camp property. The parent/guardians submitting this application are those having legal custody over the child. Conditions of custody, if applicable, will be fully communicated in writing to camp, including a photocopy of the section of any court order referring to visitation rights. I confirm that my child is capable of participating safely in the full camp program unless I advise you in writing and the camp confirms receipt of such information. I acknowledge that attendance and/or participation at Scott Mission Camp involves risk and hazards incidental thereto, all of which are assumed by me. I release The Scott Mission, The Scott Mission Camp, it trustees, directors, corporation members, staff and agents from any loss, personal injury, accident, misfortune or damage to the above-named and his/her property with the understanding that reasonable precautions shall be taken to ensure the health and safety of the above-named camper. I hereby consent to the use by the Camp of my child(ren)’s photo for any of the Camp’s purposes including publicity purposes. Parent/Guardian Name(s): Signature: Office Use Only Date: Session 1 2 3 Y 4 5 SY Fee: Referred By: Pre-Camp Call: Fee Returned: Cancel: Medical Returned: Details:
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