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: ___________________________________________