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