www.durhamcollege.ca/summercamps In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, 1990, the personal information collected on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002 and may be used and/or disclosed for the purpose of organizing and/or administering approved College events. If you have any questions about the collection, use and disclosure of your personal information by the College, please contact the Freedom of Information and

Protection of Privacy Coordinator, 2000 Simcoe Street North, Oshawa, ON, L1H 7K4, 905.721.2000 ext. 3292 . Page 1

Durham College Centre for Professional and Part-time LearningSummer Camps 2020

Camper Information/Emergency Contact/Medical Disclosure Form Please return by email or fax as soon as possible before the first day of camp. Email: summercamps@durhamcollege.ca Fax: 905-721-3195

Camper’s Name: _____________________________________ Date of Birth: (MM/DD/YYYY) _____________ Age: _________

Parent/Legal Guardian Email Address: ___________________________________________________________

May we use the above email address to contact you regarding camp information and future camp sessions? Yes No

Which camp have you registered your camper in? (Check each box that applies)

Please note: Camper to Counsellor ratio is 12:1 for all camps.

Contact/Emergency/Medical Info

Parent/Legal Guardian Name: ________________________________________________________________

Phone (home): ______________________________ Phone (cell): ______________________________

Emergency Contact: __________________________ Relationship to child: _______________________

Phone (home): ______________________________ Cell Phone: ________________________

Medical Information Please indicate any medical concerns the instructor and counsellors should be aware of to ensure a safeenvironment for your child. (Allergies/medical alert etc.):

Child Information for Identification in an Emergency

Durham College is committed to providing a safe campus environment and to the safety of your camper. To assist in this regard, we request that you complete the information below. The information provided will remain confidential and will only be used or released in accordance with the Freedom of Information and Protection of Privacy Act (FIPPA), 2002, RSO 1990, c F.31 or in the event of compelling circumstances affecting my camper’s health and safety. At the end of the camp, the information will be destroyed in accordance with applicable law and the College’s Information Management policy and procedure.

Upon arrival at camp, Durham College Campus ID staff will take a photo of your camper for an identification badge, which will be kept on file for the duration of the camp. At the end of the week, your camper will be given the ID badge to take home.

Camper’s Height: _____ Feet _____ inches or _____ cm Weight: _____ lbs or _____ kg

Hair: Colour Eyes: Colour

Glasses: Yes No Orthodontic Braces: Yes No

Unique Physical Characteristics: (such as marks, scars, exceptionality or other)___________________________________

http://www.durhamcollege.ca/summercampsmailto:summercamps@durhamcollege.ca

www.durhamcollege.ca/summercamps In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, 1990, the personal information collected on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002 and may be used and/or disclosed for the purpose of organizing and/or administering approved College events. If you have any questions about the collection, use and disclosure of your personal information by the College, please contact the Freedom of Information and

Protection of Privacy Coordinator, 2000 Simcoe Street North, Oshawa, ON, L1H 7K4, 905.721.2000 ext. 3292 . Page 2

WAIVERS: CODE OF CONDUCT

We want you to have the assurance that your camper(s) will be enjoying their camp experience in a positive, safe, enjoyable environment. The following Code of Behaviour is designed to provide you with that assurance.

Safety and Behaviour – Durham College recognizes the right of campers to have a safe, productive learning experience and to foster a tolerant environment. Therefore, campers are expected to adhere to the code of behaviour as detailed below and explained during the first day of each camp session. Campers and parents should be aware that the following are non-negotiable, “return-home” situations. If a student is sent home for any one of the reasons listed below, no refund will be given.

Failure to remain with your camp group and counsellor, unnecessary wandering of the facilities. Violating safety rules such as climbing on furniture, abuse of equipment.

Unwillingness to participate in the planned program and scheduled activities.

Violation of fire regulations.

Rudeness or unwillingness to follow instructions and reasonable directions. Disrespect towards another’s rights and privileges.

Disrespect towards the facilities.

Invasion of privacy, such as entering the washroom areas of the opposite gender.

Use of alcohol, cigarettes, narcotics or any illegal substance.

ASSUMPTION OF RISK, RELEASE, WAIVER AND DISCHARGE

Please read this document carefully before indicating your agreement below. Checking the box confirms that you have read, understood, and accepted this release, waiver and discharge.

I am aware that my camper’s participation in Durham College camp/s involves certain inherent risks, dangers and hazards, which may include but not be limited to illness, accidents or injuries, slips, trips, falls and collisions, as well as exposure to customs and practices different from my own. I understand that Durham College cannot accept responsibility for the acts or omissions of independent agencies including the operators, providers of food service and any medical treatment required. I understand that I am responsible for my camper’s health, medical, dental and property insurance.

In consideration of the acceptance of my application for my camper to participate in the Durham College Summer Camp Programs, I hereby agree to release, waive, and discharge any and all claims, demands, damages, costs, actions, and causes of action that I have or may have in the future, against Durham College and University of Ontario Institute of Technology, their directors, officers, employees, agents, representatives, volunteers and assigns, in respect to death, injury or damage, that I, my camper or any third party may suffer directly or indirectly, as a result of my camper’s participation in the Durham College Summer Camp Programs.

PHOTO, VIDEO AND MEDIA CONSENT

In the course of camp activities, pictures may be taken and recordings may be made. Please indicate below if you are not willing to have your camper(s)’ photographed or recorded.

Without compensation of any kind, I on behalf of my camper(s), hereby give Durham College the right and permission to do the following in any of its promotional materials including advertisements, publications, posters, websites, videos, etc.:

Create photographic or electronic records containing my image and/or communications related to my attendance at Durham College including classroom participation, use of campus facilities, laboratories, training, sports, clubs or any extra-curricular matter;

Copyright the photographic or electronic records containing my image and/or communications in its own name or in any other namewhich it may choose;

Telecast the photographic or electronic records one or more times over any Internet site, station or stations, to publicize any portion thereof by any means, for any purpose whatsoever in whole or part, including – but not limited to - promotion, advertising or trade;

Use my name in connection therewith if it so chooses; and

Forward the photographic or electronic records containing my image and/or communications to media outlets for use in articles or audio visual programs promoting the college.

I acknowledge that Durham College is, and will be the sole owner of all rights in and to the photographic or electronic records thereof, for all purposes indicated above in perpetuity. I hereby assign any copyright or publicity rights, or any other rights that I may have regarding the photographic or electronic records to Durham College.

I also release Durham College, its governors, officers and employees (Releasees), by reason of the use of these photographic or electronic records from any and all claims of any nature which I could, or might have against the Releasees by reason of any fact or matter whatsoever.

By checking the boxes below, I acknowledge that I have read, understand and agree with the contents contained within the above:

Code of Conduct:

Assumption of Risk Release, Waiver and Discharge:

Photo, Video and Media Consent: I give consent as outlined: I DO NOT give consent as outlined:

http://www.durhamcollege.ca/summercamps

In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, 1990, the personal information collected on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002 and may be used and/or disclosed for the purpose of organizing and/or administering approved College events. If you have any questions about the collection, use and disclosure of your personal information by the College, please contact the Freedom of Information and Protection of Privacy Coordinator, 2000 Simcoe Street North, Oshawa, ON, L1H 7K4, 905.721.2000 ext. 3292.

PERMISSION TO RELEASE CAMPER FROM CAMP EACH DAY (REQUIRED)

Camper’s Name:

Camp Name:

OPTION #1:

If you require someone other than the parent or legal guardian to pick up your child from camp, please complete the information below:

Parent/Legal Guardian Name:

Person picking up camper: (other than parent or guardian)

Days the camper will be picked up by this person:

Parent/Legal Guardian Signature:

Date:

OPTION #2

If your camper is taking PUBLIC TRANSPORTATION, please indicate your permission to release your child without your daily signature.

Your child will be walked to the on-campus bus stop by a counsellor each day to ensure he/she boards the bus safely.

Bus Number or Route: __________________________________________

Parent/Legal Guardian Name:

Parent/Legal Guardian Signature:

Date:

OPTION #3

If you are granting permission to allow your camper to sign themselves out each day, please indicate your permission to release your camper without your daily signature.

Parent/Legal Guardian Name:

Parent/Legal Guardian Signature:

Date:

In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, 1990, the personal information collected on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002 and may be used and/or disclosed to administer the Durham College Summer Camp. Your personal information may also be used for various administrative, statistical and/or research purposes of the College and/or ministries and agencies of the Government of Ontario and the Government of Canada. If you have any questions about the collection, use and disclosure of your personal information by the College, please contact the Freedom of Information and Protection of Privacy Coordinator, 2000 Simcoe Street North, Oshawa, ON, L1G 0C5, 905.721.2000 ext. 3292.

Permission and Waiver to Dispense Medication Form:

Camper’s Name: Address:_____________________________

Camp: Date:

Medical/Behavioural Info:__________________________________________________________

Is Medication required during camp? No

YES Please complete the Permission & Waiver to Dispense Medication Form below

Camper’s Health Card#: ___________ Parent/Legal Guardian Name: _____________________

Daytime Phone #: ____________________Emergency Phone #: ________________________

Doctor’s Name:______________________________Phone: ____________________________

Medication Information:

1. Name of Medication: Dose:

Time to Administer: Storage:

Dispensing Information:

2. Name of Medication: Dose:

Time to Administer: Storage:

Dispensing Information:

3. Name of Medication: Dose:

Time to Administer: Storage:

Dispensing Information:

OTHER INFORMATION:

I understand that it is my responsibility to give the medication directly to program staff with full instructions

in original prescription bottles only. In all cases, medication dispensing can only be changed or modified by

completing another Permission and Waiver to Dispense Medication Form.

I hereby acknowledge that the above information provided for the dispensing of medication for my camper,

guardian, ward, or other family member is accurate. I also understand that it is my responsibility to inform

the Durham College Centre for Professional and Part-time Learning Summer Camp of any changes in thedispensing of medication.

Parent/Guardian Name (please print) Parent/Guardian Signature Date

Date of Birth MMDDYYYY: Age: ParentLegal Guardian Email Address: May we use the above email address to contact you regarding camp information and future camp sessions Yes: OffNo: OffParentLegal Guardian Name: Phone home: Phone cell: Emergency Contact: Relationship to child: Phone home_2: Cell Phone: environment for your child Allergiesmedical alert etc 1: environment for your child Allergiesmedical alert etc 2: environment for your child Allergiesmedical alert etc 3: Feet: Weight: lbs or: Colour: Colour_2: Unique Physical Characteristics such as marks scars exceptionality or other: Glasses: OffYes: OffOrthodontic Braces: OffYes_2: OffText1: Check Box16: OffText3: Text4: Campers Name: Camp Name: Person picking up camper: Days the camper will be picked up by this person: Date 1: ParentLegal Guardian Name_2: Date 1_2: ParentLegal Guardian Name_3: Date: Address: Camp: MedicalBehavioural Info: Phone: Name of Medication: Dose: Time to Administer: Storage: Dispensing Information: Name of Medication_2: Dose_2: Time to Administer_2: Storage_2: Dispensing Information_2: Name of Medication_3: Dose_3: Time to Administer_3: Storage_3: Dispensing Information_3: ParentGuardian Name please print: Date_2: Text2: Check Box5: OffCheck Box6: OffCheck Box3: OffCheck Box4: OffCheck Box7: OffCheck Box1: OffCheck Bo: OffCheck Box2: Offnfdg: Offdfase: Offasedfe: Off