Township of Brock Summer Day Camp 2015 Registration Form
Camp Hours: 8:30-4:30 Monday- Friday
*Ages 4-12 as of July 1, 2015
CHILD’S INFORMATION
First Name:___________________________
Birthdate:(mm/dd/yyyy):________________
Last Name:_________________________
Age as of July 1 2015:________ Gender: M
F
PARENT/GUARDIAN ONE:
Name:__________________________ Email:_________________________________ Phone #:____________________
Address:________________________ City: _______________ Postal:_____________ Cell #: ______________________
PARENT/GUARDIAN TWO:
Name: __________________________ Email:_________________________________ Phone #:____________________
Address:________________________ City: _______________ Postal:______________ Cell #:______________________
ALTERNATE EMERGENCY CONTACT:
Name:_____________________________ Relation:______________________ Phone Number:_____________________
Name:_____________________________ Relation:______________________ Phone Number:_____________________
CAMP SESSION:
Please check the sessions and locations you would like to register for.
Day Trips are included in the registration fee.
Sunderland
1
2
3
4
5
6
7
Cannington
1
2
3
4
5
6
7
Beaverton
1
2
3
4
5
6
7
Session
Dates
Super
Early Bird
Early Bird
before June 1
Regular
Price
$90
$100
8
8
8
Camps run at the Arena Community
Centres in each location.
Themes (Tues, Thurs, Fri)
Trips (Wednesdays)
*Wed & Thurs – short weeks
before May 1
1
2
June 29, 30
July 2, 3
July 6-10
$80
$100
$110
$120
3
July 13-17
$100
$110
$120
4
July 20-24
$100
$110
$120
5
July 27-31
$100
$110
$120
6
7
August 4-7
August 10-14
$80
$100
$90
$110
$100
$120
8
August 17-21
$100
$110
$120
Canadian Pride, Hawaiian
Hullabaloo
Space is the Place,
Survivor, Groovy Hippies
Valentines, Dirt don’t hurt,
Mighty Jungle
Monsters Vs. Aliens, Wild
West, Red Carpet
Disco Fever, Disney,
Christmas in July
Easter, Pirate Party
Halloween, Olympics,
Mexican Fiesta
Safari Adventure, Amazing
Race, Dino Doom
Cedar Water Park
*Trip on Tuesday
Roxy Theatre/
Splash Pad
Bowmanville Zoo
Roller Skating
Place
Putting Edge
Neb’s Fun World
Elmvale Zoo
Rounds Ranch
Payment in full is required before May 1st for Super Early Bird Price and June 1st for Early Bird Price. Please forward
cheque for full amount payable to the Township of Brock. Sessions with insufficient registration will be cancelled one
week in advance. A full refund will be issued if your child cannot be transferred to another session.
Total Fee:__________________
Cash:
Cheque:
Any questions regarding Summer Day Camp please contact Alicia Bagshaw, Recreation and Leisure Coordinator.
[email protected] / 705-432-2355 ext. 243
Completed forms should be sent to the Township of Brock Municipal Office
TOWNSHIP OF BROCK, 1 CAMERON ST. E., P.O. BOX 10, CANNINGTON, ON L0E 1E0 (705)-432-2355
MEDICAL INFORMATION:
Please indicate if the camper experiences or has experienced any of the following condition(s):
Severe Allergies
ADD/ADHD
Physical Limitations
Other Special Needs
Specify medical or special need:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is medication required to be taken at camp?
Yes
No
If yes, Please give procedure and time of day_______________________________________________
I understand it is the child’s responsibility to look after and administer their own medication while at camp unless they
are not physically able.
I give the Township of Brock permission to administer the medication in cases of emergency.
Parent Signature:_____________________________________Date:_____________________________________
PICK UP DROP OFF:
In the event that I/We are not able to pick up my/our child, he/she has my/our permission to leave with the following
individual(s):
Name:_____________________ Relation:________________
Name:_____________________ Relation:_________________
WALK HOME:
I, __________________, give permission for my child, __________________, to walk home at the end of camp at 4:30.
MEDIA CONSENT:
Township of Brock Summer Day Camp would like to promote the activities that the children participate in for future participants in
camp. In order to do this we require your consent for your child’s picture to be used in this promotional material (brochures,
newspapers, slide shows etc.)
I, _____________________, give permission for my child, ______________________, to have his/her picture taken and used for
advertising purposes by The Township of Brock Summer Day Camp.
Parent/Guardian Signature: ____________________________ Date:____________________
Informed Consent Release and Waiver of Liability Indemnity Agreement. This form must be read and signed for your child to
participate.
ELEMENT OF RISK
This activity/program may present various elements of risk. Accidents resulting from such activities may occur and cause injury.
These accidents result from the nature of the activity and can occur without any fault on either the part of the Township of Brock or
its employees or agents. By choosing to allow your child to participate in the Summer Day Camp, you are assuming the risk of an
accident occurring.
ACKNOWLEDGEMENT
I, __________________________________________, understand and accept the above and provide the Township of Brock, its
employees or agents with the following waiver of liability and indemnification agreement.
RELEASE AND INDEMNIFICATION AGREEMENT
I, __________________________________________, hereby release the Township of Brock and its staff and agents from any and all
liability for any injury sustained by my child, regardless of how caused, resulting from my child’s participation in the Summer Day
Camp arranged through the Township of Brock. I further agree to indemnify and save harmless the Township of Brock and its staff
and agents from any and all suits, demands, torts, and actions of any kind which may be brought against its staff or agents for which
it/they may become liable by reason of any injury, loss, damage or death resulting from, or occasioned to, or suffered by any person
or any property, by reason of any act, neglect or default of my child.
I HAVE READ THE ABOVE AND UNDERSTAND THAT I AM ASSUMING THE RISKS ASSOCIATED WITH MY CHILD PARTICIPATING IN
THE TOWNSHIP OF BROCK SUMMER DAY CAMP.
Parent/Guardian Signature: ______________________________________Date: ___________________________________
TOWNSHIP OF BROCK, 1 CAMERON ST. E., P.O. BOX 10, CANNINGTON, ON L0E 1E0 (705)-432-2355