Child’s InformationChilds name*DOB (m/d/y)*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age as of July 8, 2020*MSP #*Current swim level*Allergies, dietary requirements or sensitivities including vegetarian, no dairy, no pork etc*Medical conditions including medications*Family Doctor Name (walk in clinic name required if no doctor)*Family Doctor Phone Number (walk in clinic phone number required if no doctor)*My child is immunized...*I'll attach documentationAlready on file with OSCI choose not to immunizeImmunization documentation Drop files here or Childs dentist and phone number*1. (First) Parent/guardian InformationParent/guardian name*Occupation*Relationship to child*Home address*Postal code*Home phone number*Work phone numberExt.Cell phoneEmail2. (Second) Parent/guardian InformationParent/guardian nameOccupationRelationship to childHome addressPostal codeHome phone numberWork phone numberExt.Cell phoneEmailAuthorized Pick-Up ContactsThe following people are authorized to pick-up my child from the Club:1. Authorized Person's Name:*2. Authorized Person's Name:*3. Authorized Person's Name:4. Authorized Person's Name:5. Authorized Person's Name:Emergency ContactsThree local contacts, 19+ other than parent/guardian, are required in the event of an emergency or to care for my child if my child is ill and the Club is unable to contact me: 1. Emergency Contact Name:1. Emergency Contact Primary Phone #:2. Emergency Contact Name:2. Emergency Contact Primary Phone #:3. Emergency Contact Name:3. Emergency Contact Primary Phone #:Authorization* I authorize the staff at the Sir James Douglas Out of School Club Child Care facility to call a physician or summon an ambulance for emergency medical aid should the person(s) in attendance feel such services are required for my child. If such an emergency should arise, I shall be notified as soon as possible. I agree that any cost incurred for such services shall be the sole responsibility of myself. Risk acknowledgement and assessmentAwknowledgement* I waive any liability on the part of the Sir James Douglas Out of School Club (the Club) and any of its employees, directors, agents or representatives if my child is injured on the playground equipment, in the Club or on field trips away from the Club premises. I fully understand that reasonable precautions and safety measures will be taken by the Club staff; however, I acknowledge that children may receive injuries even under close supervision. Awknowledgement* SJD OSC travels to out-trip locations by public transport, rental bus or on foot. I understand precautions and safety measures will be taken by the SJD OSC staff and acknowledge the risks associated with travel and transportation. Awknowledgement* I waive any liability on the part of the Sir James Douglas Out of School Club (the Club) and any of its employees, directors, agents or representatives for any act or omission of any of its staff members hired by me to provide child care, housecleaning and other services. I understand that, if I/we hire staff of the Club, that the Club is not responsible and all risks associated with such engagements are born solely by me/us and the worker(s). I acknowledge that Club staff so engaged are not covered by the Club or Club’s insurance or WCB insurance. Parental AgreementsDates my child will attend* Day #1: Wednesday September 9, 2020 $40.00/DAY Day #2: Thursday September 10, 2020 $40.00/DAY Day #3: Friday September 11, 2020 $40.00/DAY Cost of each day/camp is $40.00 per day payable by e-transfer once we have confirmed your registration. Acknowledgement* I acknowledge and agree that the information that I have provided in this Registration Form is correct and complete. I further agree that we are responsible to, and that I will, advise the Club of any changes to this information in a timely manner. Acknowledgement* For the time my child is enrolled at Sir James Douglas Out of School Club Camps, I agree to abide by the Club’s Policies including: § I have provided 25% non-refundable deposit with registration to ensure enrollment via cheque or e-transfer to firstname.lastname@example.org “Fairfield” is security answer. § I understand payment for the full remainder of camp fees is due 14 days prior to camp start date. If choosing to withdraw within 13 days of camp start date, a refund of 50% will be granted. NO refunds will be issued after start date of camp(s) you wish to withdraw from. § I am aware that no rebate of fees will be allowed for absence due to illness or any other reason. § To drop off my child directly to a staff member, advise staff of departures and use the sign-in/sign-out sheet posted. I also agree to adhere to program start and finish times 8:00 am – 5:30 pm. I understand that this policy is strictly enforced and a fine of $10.00 for every quarter hour or portion thereof, will be levied for tardy pickups. I understand that if I am repeatedly late, that this is grounds for the termination of my contract. § To notify staff if my child is unable to attend camp on any given day, due to illness, holidays, etc by testing/calling 250-217-4445. If my child is ill, I will make other arrangements for his/her care and advise the Club of any communicable diseases or lice, that may affect other children, or the care of the child involved. § To notify the Club Director/Supervisor, in writing of any changes, new information or special circumstance regarding my child. To notify the Club Director/Supervisor in writing of any and all people authorized to deliver and/or pick up my child. § To notify the Club Director/Supervisor in writing of any and all persons not permitted access to my child. Date of submission*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Name of signer*2. Name of signerNameThis field is for validation purposes and should be left unchanged.