Application Form
Summer Camp 2014
APPLICANT’S INFORMATION
First Name: ______LastName: ______
Preferred First Name: ______
Gender: Male Female
Home Address:______
City:______Province: ______Postal Code: ______
Age of Participant:(As of June 23, 2014) ______
Birth date: (MM/DD/YYYY) ______
PARENT / GUARDIAN INFORMATION
First Name(s): ______
Last Name(s): ______
Home Address: Same address as child See below
Home Address:______
City:______Province: ______Postal Code: ______
Email Address: ______
Home Phone: (______) ______
Work Phone: (______) ______Ext.______
Cell Phone: (______) ______
Are there any friends with whom your child would like to be grouped?
______
PROGRAMME SELECTION ~ CAMPS & WORKSHOPS:
Please select the program(s) you wish to enroll your child in by checking the box beside the program. All programs run from 9am to 4pm. Children must bring their own lunch and snacks.
Full time ($200/week) / Part time ($40/day)Mon Tues Wed Thurs Fri / June 23–June 27th Myth Busters
Full time ($160/week) / Part time ($40/day)
Mon Wed Thurs Fri / June 30 –July 4 International Week
Full time ($200/week) / Part time ($40/day)
Mon Tues Wed Thurs Fri / July 7- 11 Time Travellers 1
Full time ($200/week) / Part time ($40/day)
Mon Tues Wed Thurs Fri / July 14-18 Time Travellers 2
Full time ($200/week) / Part time ($40/day)
Mon Tues Wed Thurs Fri / July 21- 25 Game Show Week
Full time ($200/week) / Part time ($40/day)
Mon Tues Wed Thurs Fri / July 28- Aug 1 Trash n’ Treasure Week
Full time ($160/week) / Part time ($40/day)
Tues Wed Thurs Fri / Aug 5- 8 Look Inside Week
Full time ($200/week) / Part time ($40/day)
Mon Tues Wed Thurs Fri / Aug 11- 15 Fuzzy WuzzyCreepy Crawly
Full time ($200/week) / Part time ($40/day)
Mon Tues Wed Thurs Fri / Aug 18- Good Ol’ Camp Week
EXTENDED DAY:
Children enrolled and paid as full week attendees at the Summer Camp receive extended day drop off and pick up at no extra charge.
Children enrolled as students with Touchstone Academy as part of the academic program for fall 2014 receive extended day drop off and pick up at no extra charge, regardless of whether the child is in the Summer Camp full time or part time.
If your child is enrolled part time and is not a Touchstone Academy student for fall 2014, and are interested in the Extended Day option, please select the day(s) that you require the Extended Day service by checking the corresponding boxes below.
OptionHoursCostMonTuesWedThurFri
Early Morning7:30-9am$5/day
Late Afternoon4-6pm$5/day
Additional Child Discount: Each family who registers more than one family child in the Summer Camp will receive a 10% discount on the fees applicable to the second and subsequent family children.
Priorities and Waiting List: Placement priority will be given to those families who commit to full week(s). Part time availability is dependent on remaining available spaces. Touchstone will maintain a waiting list and e-mail families as commitments change through the summer.
HEALTH INSURANCE:
Medicare / Health Insurance Number: ______Expiry Date: ______
MEDICAL INFORMATION:
Please provide an alternate emergency contact.
Contact Name: ______
Relationship to Child: ______
Home Phone: (______) ______
Work Phone: (______) ______Ext. ______
Cell Phone: (______) ______
Please list any medical conditions of your child of which the Summer Camp needs to be aware to ensure a positive summer experience: ______
Please list any allergies: ______
Please list any dietary restrictions: ______
Please note all medications your child will be taking during Summer Camp:______
Does your child have any activity restrictions? If yes, please provide details.
______
Is there any information about your child that you feel may be helpful for our staff to know?
______
PERMISSION:
By signing this application you give permission for your child to be transported by a staff member or a vehicle driver hired by Touchstone Academy.
You also give permission for photographs of your child to taken and used for promotional purposes.
Signature: ______Date: ______
INDEMNITY:
It is acknowledged that participation in camp activities involves inherent risks and related hazards incidental thereto, and the undersigned does hereby waive, release and absolve and agree to indemnify and save harmless the School, its governors, officers, employees, volunteers and agents of and from any and all liability arising in any manner whatsoever from such participation by the applicant, except such liability as shall arise as a sole consequence of the negligence of those persons named.
I ______permit my child(ren)______to attend Touchstone Academy Summer Camp, and to participate in the full range of camp activities. In the event of an accident or illness affecting the above named child, I authorize Touchstone Academy to administer all procedures necessary therein, as Touchstone Academy may deem essential for the care and well-being of the child. In the event that I can not be reached, I hereby give permission to the physician selected by the staff member to transport the child to hospital and secure proper treatment. To the best of my knowledge, the information on this form is accurate and complete.
CONDUCT: All registrants will respect the instructors, other participants, the facilities and grounds and will abide by the Touchstone Academy rules. Failure to do so may result in immediate expulsion from the Summer Camp, without a refund of payment.
REFUND POLICY: A refund will be issued to any participant withdrawing from a programme prior to June 1, 2014. All refunds are subject to a $25 administration fee.
Please Note: All campers must be toilet trained.
PAYMENT INFORMATION:
Full payment and completed registration forms are required at the time of registration. Post-dated cheques are acceptable. All programmes require a minimum number of participants and may be cancelled if there is insufficient enrollment, in which casea full refund will be given.
Applicant’s Name:______TotalAmount Payable: $ ______
PAYMENT OPTIONS:
Cheque or Money Order (enclosed)
(Please make cheques payable to Touchstone Academy.)
MasterCard
Visa
Card Number:______Expiry Date (mm/yy): ______/______
Name as it appears on card: ______Authorized Signature:______
(506) 847–2673, by Fax at(506) 849–9582
68A Hampton Road, Rothesay, NB
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