CAMP PROMISE AFTER SCHOOL PROGRAM APPLICATION FORM

PROGRAM NAME

CAMP PROMISE AFTER SCHOOL PROGRAM

Fall 2015- Spring 2016

Program Bethel Community Church

Location 128 St Vincent Street Barrie, ON L4M 3Y8

Program Time

3:30pm – 5:30pm Wednesdays and Thursdays

Start DateWednesday September 16, 2015

End DateThursday May 19, 2016

CostFree

Meet: At Program Location above OR

Pick Up location at Oakley Park School at 3:20pm

Contact Person

Camp Director: Tracy Robinson

PLEASE BRING HOME WORK AND ANY COMMUNICATION BOOK USED WITH CLASSROOM TEACHER

APPLICATIONS CANNOT BE ACCEPTED IF INCOMPLETE. PRINT CLEARLY IN BLUE OR BLACK INK

CHILD/YOUTH INFORMATION

Last Name

First Name

M.I.

Date of BirthDMY

Age

GenderMALEFEMALE

Health Card Number (Required)

Medical Conditions or Allergies

Special Needs (i.e. ADD/ADHD, Autism, Learning Disabilities)

Name of School

Grade

Name of Teacher

PARENT/GUARDIAN INFORMATION

Last Name

First Name

M.I.

Street Address

Apartment/Unit #

City

Province

Postal Code

Home Phone()

E-mail Address

Cell Phone()

Other Phone()

EMERGENCY CONTACT

Last Name

First Name

M.I.

Home Phone()

Cell Phone()

Relationship to child/youth

Alternate Contact

Home Phone()

Cell Phone()

Relationship to child/youth

ACKNOWLEDGEMENT

I hereby grant permission for my child to participate in all the activities of this program (which may include outings during program hours) and release Camp Promise and staff from any and all liability, claims, demands, personal injury, sickness, death, as well as property damage and expenses of any nature whatsoever, which may be incurred by the child participant. Further I grant permission to Camp Promise staff to authorize medical personnel to carry out any emergency procedure on my child in the case that I, or my emergency contact, cannot be reached at the time of the incident. In addition, I understand that photographs/videos of my child taken during program may be used for promotional material. I have read and understood this waiver.

Parent/Guardian Signature

Date

Camp Promise @ Bethel Community Church 128 St. Vincent Street Barrie, ON L4M 3Y8 Tel: 705-722-5221 Fax: 705-722-5082

Registered with the Canada Revenue Agency

Registration No. 128793049 RR 0001