Printable PDF version of the form available here: Spring Break camp 2019 Spring Break Camp 2019* Week 1 March 18th - 22nd - $225/wk ($56 deposit) Week 2 March 25th - 29th - $225/wk ($56 deposit) Deposit due with registration to secure a spot! Remaining funds are due 2 weeks before start date :) Childs InformationChild's Full Name*Gender*MaleFemaleBirth Date* Age as of March 18, 20195678910111213MSP Medical #Family Doctor’s NameDoctor's Phone NumberCurrent Swimming LevelAllergies and Dietary Requirements/Restrictions Medical Conditions Including Medications Parent/Guardian and Emergency Contact Information The first parent/guardian listed below will be the primary contact for billing and communication purposes. Parent/Guardian Full Name*Relationship to Child?Cell Phone #Place of Work?Work Phone #Home Address (Line 1)*Home Address (Line 2)CityHome Phone #*Email Address Second parent/guardian infoParent/GuardianRelationship to Child?Cell Phone #Place of Work?Work Phone #Home Address (Line 1)Home Address (Line 2)CityHome Phone #Email Address If you have custody orders you must attach documentation and inform Supervisors at time of registration.Accepted file types: jpg, png, pdf.Provide three local emergency contacts:Three 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: Name (1)Relationship to child (1)Home Phone # (1)Cell Phone # (1)Name (2)Relationship to child (2)Home Phone # (2)Cell Phone # (2)Name (3)Relationship to child (3)Home Phone # (3)Cell Phone # (3)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.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 AssessmentI 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. 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. 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 AgreementsI 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. 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 with ' Fairfield ' as the security question 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 – 5:30pm. 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 texting/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, as well as 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. Dated:InitialsFull Name Signature I understand the camp runs from 8:00am to 5:30pm. The charge for late pick-up is $10.00 for every quarter hour or portion thereof.* I agree I hereby give my consent for a staff member to administer first aid to my child in the case of accident or illness. Furthermore I give my consent for staff to call a medical practitioner or ambulance. Any expenses incurred in such an event are solely my responsibility.* I agree I hereby give my consent for my child to go on field trips via walking, public transportation or rental bus. I understand that every precaution and safety measure will be taken and waive any liability to the SJD OSC and program staff.* I agree I understand that I am eligible for 75% refund if I provide 2 weeks’ notice before my camp start date.* I agree This iframe contains the logic required to handle Ajax powered Gravity Forms.