Seedlings Children’s Centre Summer Camp Registration Form Child Information

Seedlings Children’s Centre Summer Camp Registration Form
Child Information
Child’s Name: ___________________________________
Home Phone: ___________________
Child’s Address:__________________________________
Language Spoken at home:
____________________________________________
Postal Code__________ Birth Date (dd/mm/yy)_________
Guardian #1 Name:
_______________________________________________
Guardian #2 Name:
______________________________________________
Email Address:
_______________________________________________
Email Address:
______________________________________________
Guardian’s Address:
_______________________________________________
Guardian’s Address:
______________________________________________
(if different from child’s address)
(if different from child’s address)
Postal Code: ____________ Cell Phone: _______________
Postal Code: ____________ Cell Phone: ______________
Other Phone: ________________
Other Phone: ________________
Medical conditions that we should know about? Including communicable diseases or medical attn. currently or in past.
______________________________________________________________________________________________
______________________________________________________________________________________________
If child has a life threatening allergy or regular medication we need you to fill out additional forms. Please notify staff.
Doctors name/Address/Phone______________________________________________________________________
Seedlings Children’s Centre Summer Camp Registration Form
AUTHORIZED PERSONS TO PICK UP CHILD
And EMERGENCY CONTACTS
Child’s Name: ___________________________________
The following people are authorized to pick up my child above from Seedlings Children’s Centre Summer Camp.
Signature of Parent/Guardian: ___________________________ Date: ___/___/___
Name: ______________________ ______________________
Pick Up: _____ Emergency Contact: ______
Phone Number: _______________ ______________________
Relationship to Child: __________________________________
Name: ______________________ ______________________
Pick Up: _____ Emergency Contact: ______
Phone Number: _______________ ______________________
Relationship to Child: __________________________________
Name: ______________________ ______________________
Pick Up: _____ Emergency Contact: ______
Phone Number: _______________ ______________________
Relationship to Child: __________________________________
Name: ______________________ ______________________
Pick Up: _____ Emergency Contact: ______
Phone Number: _______________ ______________________
Relationship to Child: __________________________________
A written and signed consent letter is required for pickup by anyone not on this list.
Please list any individual(s) who is LEGALLY DENIED access to your child. Copies of the legal documents are required.
Seedlings Children’s Centre Summer Camp Registration Form
_____________________________________________________________________________________
Attendance and Payment Information
Child’s Name: ___________________________________
DATE ADMITTED: _________________
DATE WITHDRAWN: ________________
Days Requiring care: Monday______ Tuesday ______ Wednesday_____ Thursday ______ Friday______
Hours requiring Care: Drop off Time: _______________ Pick up Time: ___________________
FEES PAID: _________________
10% Sibling Discount Y N
AMOUNT: ____________ Week ________________
Your weekly fee :___________________________________________
I acknowledge and understand that participation in and attendance at Seedlings Childcare Centre Summer Camp involves certain risks and dangers
of accidents. I understand and have considered and evaluated the nature, scope and extent of the risks involved. As well, I voluntarily and freely
choose to assume those risks.
I have read the parent handbook and I agree to comply with the policies contained in it. At this time I wish to enter into an agreement with
Seedlings Children’s Centre Summer Camp to provide care for my child.
________________________ __________________________________________
Printed names
(Signature of Parent/Legal Guardian)
_______________________ Printed Name
_______________________________________
(Supervisor Signature)
Seedlings Children’s Centre Summer Camp Registration Form
Authorizations and Release Forms
Child’s Name: ___________________________________
EMERGENCY TREATMENT RELEASE FORM
I authorize Seedlings Children’s Centre Summer Camp to act on my behalf to ensure immediate medical treatment should the staff deem it
necessary. I give permission for my child above in the event of an emergency, to receive full medical attention deemed necessary by a physician at
a hospital. If possible without leaving the centre without sufficient staff, my child will be accompanied to the hospital or met there. Every effort
will be made to reach me and/or my emergency contact person. I agree to accept any financial responsibility for any emergency medical care
necessary.
Guardians’ Signature: __________________________ ___________________________ Date: __________________________
SUNSCREEN
Parents must apply sunscreen on their child prior to them coming to camp. Please sign this form if you would like the staff at Seedlings Summer
Camp to re-apply your own sunscreen in the afternoon. I hereby give permission for the staff at Seedlings Children’s Centre Summer Camp to reapply my own sunscreen in the afternoon to my child above.
Guardians’ Signature: __________________________ ___________________________ Date: __________________________
TRIP CONSENT
This confirms that ________________________________________ is allowed to participate in planned and short walks between the hours of
7:00am and 6:00pm.
Guardians’ Signature: __________________________ ___________________________ Date: __________________________
Seedlings Children’s Centre Summer Camp Registration Form
CONSENT TO VIDEO TAPE OR PHOTOGRAPH
I grant permission for SEEDLINGS CHILDREN’S CENTRE SUMMER CAMP teachers to take photographs and/or videotapes of my child above
while in attendance at the camp. I understand that these photos or tapes may be used for educational and/or camp related purposes including:
classroom, bulletin boards, photo albums, newspaper ads and displays regarding our programs. To ensure the confidentiality, I understand that if
names are necessary only my child’s first name will be used. I understand, if my situation changes in the future and I would prefer not to have my
child photographed or taped, I will inform SEEDLINGS CHILDREN’S CENTRE SUMMER CAMP PROGRAM SUPERVISOR immediately.
Guardians’ Signature: __________________________ ___________________________ Date: __________________________
PRIVACY POLICY CONSENT
Personal information received about our students, families and emergency contacts is for the purpose of providing quality service to our families.
Information may be disclosed to staff, supply staff, Ministry of Education for licensing purposes, as well as Halton health and other legal agencies
and authorities as required. All staff members are informed in the appropriate protection of you information. Your information will be stored and
kept on file for two years after termination. Information will then be disposed of by means of shredding, or other permanent methods. The
privacy officers are the Centre Administers. I hereby give my consent for Seedlings Children’s Centre Summer Camp to collect, use and disclose
information as needed:
Parent/ Guardian Signature: _________________________________
Date: _____________________________
Supervisor’s Signature on the date of registration: ___________________________________________