Today’s Family Adventure Camp Program– Summer 2015
Please send completed registration form to: or fax to 905-574-2684Child/LIT Information
Please print. (one form per child)Child’s First Name: / Child’s Last Name: / Child’s Age:
q Male
q Female / Child Lives With: (circle one) Both Parents / Mother / Father / Guardian / Child’s Birth Date: Day/Month/Year
/ /
Home Phone No.: / Address: / Postal Code:
( )
Child’s Health Information
Family Physician Name: / Family Physician Address: / Family Physician Phone No.:( )
Has your child been immunized? / q Yes q No
Please indicate if camper has experienced any of the following: / Yes / No / Unknown /
Details
Seizures /Vision/Hearing difficulties /
Mobility difficulties /
Asthma / Inhaler must accompany child each day
Allergies
¨ Peanuts
¨ Bee stings
¨ Hay fever
¨ Medication
¨ Food
¨ Latex
¨ Other (please specify) / Epi Pen / ¨ Yes (Epi Pen must accompany child each day)
¨ No
Diabetes
Any other dietary restrictions?
Any previous major illness or operations?
Other
Other Information
Swimming Level: / q Shallow Endq Deep End / Swimming Requirements: / q Life Jacket (to be supplied by parents)
q Ear Plugs (to be supplied by parents)
Any additional swimming information?
Any additional information that would be helpful to staff when working with your child?
Please check (P) the location your child will be attending and age group
Please note that locations may be subject to change.Location / Kinder Camp
4 – 6 years
(already in JK or SK) / Adventure Camp
7 – 9 years / Camp Extreme
10 – 12 years / Leader in Training
13+ years
Burlington
C.H. Norton School
2120 Cleaver Ave, Burlington
Burlington
J.W. Boich School
2474 Sutton Dr., Burlington
Burlington
Alton Village School
3290 Steeplechase Dr., Burlington
Oakville
Brookdale School
1195 Bridge Rd., Oakville
Dundas
Knox Presbyterian Church
23 Melville St., Dundas
Hamilton East
Delta United Church
47 Ottawa St. S., Hamilton / Not available at this location.
Hamilton Mountain West
R.A. Riddell School
200 Cranbrook Dr., Hamilton
Hamilton Mountain East
Eastmount Park School
155 East 26th St., Hamilton
Stoney Creek
Collegiate Avenue School
49 Collegiate Ave., Stoney Creek
Haldimand-Norfolk
Lynndale Heights School
55 Donly Dr., Simcoe
Haldimand-Norfolk
Lakewood School
713 St. George St., Port Dover
Please check (P) the dates your child will be attending
Please request ONLY the dates you need as you will be billed for all scheduled dates, including sick and absent days.
Cancellation requests will be considered on an individual basis.
Monday / Tuesday / Wednesday / Thursday / Friday
June 29 - July 3 / Statutory Holiday
Program closed *
July 6 – 10
July 13 – 17
July 20 – 24
July 27 – 31
August 3 – 7 / Statutory Holiday
Program closed *
August 10 – 14
August 17 – 21
August 24 – 28
August 31-September 4
* You will be billed for statutory holidays if your child is enrolled with Today’s Family the week before and the week after.
Parent/Guardian Information
Please print.Parent or Guardian
First Name: / Last Name: / Address (if different from child’s):
Home Phone Number: / Cell Phone Number: / Relationship to child:
( ) / ( )
Employer: / Employer Address: / Employer Phone Number:
( )
Parent or Guardian
First Name: / Last Name: / Address (if different from child’s):
Home Phone Number: / Cell Phone Number: / Relationship to child:
( ) / ( )
Employer: / Employer Address: / Employer Phone Number:
( )
Emergency Information
Please fill out the names of two people who we can contact in the event of an emergency and the parents/guardians are not available.Name of adult friend or relative (local): / Relationship to Child: / Home Phone Number: / Business Phone Number:
( ) / ( )
Name of adult friend or relative (local): / Relationship to Child: / Home Phone Number: / Business Phone Number:
( ) / ( )
Persons Authorized To Pick Up Child
The following person(s), other than the parents/guardians are authorized to pick up child:
Name: / Relationship to Child: / Home Phone Number: / Business Phone Number:( ) / ( )
Name: / Relationship to Child: / Home Phone Number: / Business Phone Number:
( ) / ( )
Some activities and trip destinations that my child and I are interested in include:
Child’s age: / Location:
Permission
Please note the following excursion days: / Bronte Creek Provincial Park and Byng Island Conservation Area / Trip DaysKinder Camp (4 – 6 years) / Thursdays / Tuesdays
Adventure Camp (7 – 9 years) / Burlington locations – Mondays
Dundas location – Mondays
Delta location – Tuesdays
Collegiate location – Tuesdays
Linden Park location – Fridays
Eastmount Park - Fridays
Riddell location – Fridays
Haldimand-Norfolk Locations - Tuesdays / Thursdays
Extreme Camp (10 – 12 years) / Mondays
Tuesdays
Thursdays
Fridays / Wednesdays
I am aware that the children go on weekly excursions and daily outings such as community parks. I give my permission for my child to attend excursions under the supervision of Today’s Family Staff. I understand that most excursions will involve transportation by school bus or city bus.
Parent/Guardian Signature:
On occasion, pictures may be taken of the campers in the program. Please check “yes” if these pictures can be used for Today’s Family advertising and promotion.
q Yes q No
I have read and understand the information regarding the Adventure Camp Program and further clarification is available at our locations or .
Signature of parent/guardian : ______
Date: ______
Cancellation Policy
Cancellation requests will be considered on an individual basis.
Registration Information
You must submit all of the following items to complete camp registration:
· Fully completed Registration form
· Copy of Subsidy Authorization for Today’s Family Camp (if subsidized)
· Payment
Payment Information
q Fee Paying / q Subsidized
A copy of your Subsidy Authorization for Today’s Family Camp must be attached.
Parent Contribution $______
Note: If your Subsidy Authorization is not attached you must pay the fee paying rate.
Daily Rates:
Kinder Camp / $39.10
Adventure Camp / $37.90
Camp Extreme / $37.90
Leader in Training (ages 13 - 16) / $ 9.90
A one-time $25 registration fee must be submitted with this camp registration for new customers only (unless Subsidy Authorization is attached).
Payment is required for all days registered including sick or absent days and for statutory holidays where the child is registered with Today’s Family the week before and the week after the statutory holiday.
Payment calculator: / number of days / x / daily rate or contribution / = / total due
Requested days in July / x / $ / = / $
Requested days in August / x / $ / = / $
Registration fee ($25.00 for new customers only, if not subsidized) / $
Total payment due / $
Payment methods:
By mail – cheque* (can be post-dated no later than June 15, 2015 for July camp and no later than July 15, 2015 for August camp), money order, or credit card (see next page)
By e-mail – e-transfer (please contact Accounting at 905-574-9344, ext. 203)
By phone – credit card (please contact Accounting at 905-574-9344, ext. 203)
In person at Today’s Family, 44 Greendale Drive, Hamilton – cash, cheque, money order, debit, Visa or Mastercard
* NSF cheques will be subject to a $25.00 administration fee.
If paying by credit card please complete this section or contact Accounting at 905-574-9344, ext. 203.
Name of Credit Card Holder:
Type of Credit Card (please circle): / Mastercard / Visa
Credit Card Number / Expiry Date (mm/yy)
/
I/we authorize Today’s Family Early Learning and Child Care to charge my credit card as follows:
q Payment in full on ______(date, must be no later than June 15, 2013)
q Payment of $______for July camp on ______(date, must be no later than June 16, 2014)
q Payment of $______for August camp on ______(date, must be no later than July 15, 2014)
Signature of cardholder:
Child’s Name:
Camp Location:
Parent/Guardian Name:
Address:
Phone Number:
H:SummCamp\2015 Page 6 of 6