| General Information |
| Child's Name: |
|
| Gender: |
|
| Date of Birth: |
/
/
|
| Age at Camp: |
|
| Grade in 2009/10: |
|
| Address: |
|
| |
|
| City: |
|
| Province: |
|
| Postal Code: |
|
| Phone Number: |
(
)
-
|
Family Email:
(A
copy of this form will be sent to this address) |
|
| Parent/Guardian 1: |
|
Address:
(If different from above) |
|
| |
|
| Home Phone: |
(
)
-
|
| Business Phone: |
(
)
-
|
| Cell Phone: |
(
)
-
|
| Parent/Guardian 2: |
|
Address:
(If different from above) |
|
| |
|
| Home Phone: |
(
)
-
|
| Business Phone: |
(
)
-
|
| Cell Phone: |
(
)
-
|
| Legal Custody: |
|
| If Guardian, please state relationship to child: |
|
| Alternate parental phone number while child is at camp (ie. cottage phone number): |
(
)
-
|
Alternate Emergency Contact (if parent
cannot be reached): |
|
| Relationship: |
|
| Address: |
|
| |
|
| Phone Number: |
(
)
-
|
| What size t-shirt does your child require? |
|
| |
|
| Cabin Mate Request |
| We will try to honour one mutual request for campers of the same age. Please list a maximum of 2 names. |
| Name 1: |
|
| Name 2: |
|
| |
|
| Camp Selection |
| Please choose section and dates. |
|
|
| |
|
Transportation
|
| Does your child require transportation to Kenora on the 1st day of camp? |
Yes
No |
| Does your child require transportation to Winnipeg on the last day of camp? |
Yes
No |
| Other than parent/guardian stated above, please list people permitted to sign your child in/out: |
|
| I authorize my child to sign themselves in and out of Camp Stephens (Youth aged 13+) |
Yes
No |
| |
|
| Health History |
| General Information |
| Height: |
|
| Weight: |
|
Health/Medical # :
(Manitoba 6 digit) |
|
Health/Medical # :
(Manitoba 9 digit) |
|
Are your child's immunizations up
to date? |
Yes
No |
| Special Needs |
| Does your child require additional assistance or additional adult assistance due to Special Needs? |
Yes
No |
| Has your child been diagnosed or in the process of being diagnosed with any of the following? |
ADD
ADHD
ODD
PDD
Asperger's Syndrome
Other:
|
| Does your child ever take behavioural related medications? |
Yes
No |
| Allergies & Dietary |
| Does your child carry an EPI-PEN? |
Yes
No |
| Does your child use an inhaler? |
Yes
No |
Can your child administer
EPI-PEN? |
Yes
No |
| Can your child administer inhaler? |
Yes
No |
| Does your child have any allergies? |
Yes
No |
| If yes, please list allergies: |
|
| What triggers the above allergies? |
|
| What reactions to above? |
|
| Medication taken? |
|
| Does your child have any special dietary requirements (i.e. cultural, vegetarian)? |
Yes
No |
| If yes, please list: |
|
Medications
All medication must be brought to camp in its original container with the name of the camper, medication and dosage information clearly visible (a pharmacist can re-dispense medication into a small container if necessary). |
| Please list medications that your child will be bringing to camp: |
|
My child may take the following types of over the counter medications while
at camp: |
Tylenol and like products
Cough syrup & like products
Ibuprophen & like products
No medications |
Medical History
Please include any details you feel necessary. The more information you are able to provide, the better we are able to meet the specific needs of your child. For any specific problems of a confidential nature, please include separate letter to the Camp director marked "Confidential". |
| Are there any other health issues or medical concerns? |
|
|
No relevant health issues / concerns. |
Behaviour
YMCA-YWCA Camp Stephens strives to be a fun, safe and active environment where everyone has a chance to be their best. All campers, staff and volunteers pledge to treat each other with dignity and respect. Behaviour that prevents others from enjoying a positive camp experience will not be permitted. If necessary, campers may be asked to leave based upon inappropriate behaviour including swearing, aggression, or use of prohibited items such as but not limited to tobacco, alcohol, non-prescription drugs or offensive printed materials.
Photography
Photographs taken at camp may be used for public displays and/or other promotional projects about the YMCA-YWCA of Winnipeg. All photos are the property of the YMCA-YWCA of Winnipeg and may or may not be used.
Authorization
To the best of my knowledge my child is in good health. I will notify the camp in writing of any changes that occur in my child's health between completing this form and attending camp. Furthermore, I will notify the camp in writing if my child is exposed to an infectious disease during the three weeks prior to camp. I, the undersigned permit my child to participate in the full range of camp activities and authorize the Camp Director and their appointee, in the event of accident or illness affecting the above named camper, to authorize on my behalf all procedures, including admission to hospital and necessary treatment therein, as they may deem essential for the care and well-being of my child. Such action is to be taken only when immediate contact with the undersigned cannot be made. I agree to accept financial responsibility in excess of the benefits allowed by Provincial Health and/or Medical Insurance. |
|
I have read and understand the above. |
| |
|
| Credit Card Payment Options |
Please contact the Camp Stephens office at
(204) 889-8642 ext 305 with credit card information
Or download a credit card information form and
fax to 204 889.9002
Please be advised:
The Government of Ontario's Harmonized Sales Tax (HST) will apply to camp programs as of July 1 2010 unless fees are paid in full prior to May 1, 2010.
If camp fees are paid in full by April 30, 2010, The GST rate of 5% will apply. If any portion of the camp fees are unpaid by this date, the new tax rate of 13% will apply to all camp fees, aside from the CIT program.
Modified payment options for this year are as below. 5% GST will apply to the three options below:
|
| Card Type: |
|
| Payment Type: |
Pay in full at time of registration
Pay $100 deposit at time of registration. Balance due April 15.
Pay $100 deposit at time of registration. Extended equal payments on the 15th day of each month ending April 15, 2010.
Please be advised: If you do not choose one of the above options. 13% HST will apply to the option below:
|
Pay $100 deposit at time of registration. Balance due June 15.
|
| |
|
| Charitable Contribution - Thank You! |
Donations will be processed with deposits and
tax receipts issued. |
I wish to donate to the Campership Fund in
the amount of: |
|
| |
|
| Financial Policies |
Refunds will be issued no later than May 1, 2010. Requests must be made in writing. After May 1, refunds will be given for medical reasons only (medical certificate must be provided). If applicable, we will issue a refund of your camp fee less a $5 + GST service charge.
Returned Payments - In the event of return payment, service may be suspended until the account is paid in full. The association reserves the right to cancel registrations with outstanding payment. Unpaid accounts will be sent to a
collection agency. |
I have read and understand the Financial Policies.
I understand that the only way to guarantee immediate registration is to register in person. All other registrations are processed in the order they are received.
Assumption of Risk and Indemnifying Release - While YMCA-YWCA staff and instructors will make every reasonable effort to minimize exposure to known risks, I understand that in registering my child in a YMCA-YMCA Camp Stephens program, my child will be involved in physical activities and that with any physical activity, there is a risk of injury.
I do hereby release the YMCA-YWCA of Winnipeg, and its respective officers, directors, employees, volunteers and agents, and their successors and assigns, from all liability for damages sustained in consequence of loss, injury or damage to myself or my child, and from all other actions, causes of action, claims, demands or damages of any kind with respect to death, injury, loss or damages to any person or property including myself or my child arising out of or connected with preparation for, or participation in YMCA-YWCA programs or activities.
|
| |
| Name of Parent / Guardian: |
|
