Camp Enrollment Form

Butterfly Camp Registration

Summer 2021
For Office Use ONLY- File Admission Date
For Office Use ONLY- File Discharge Date
Choose Your Adventure!

Pick your favorite weeks and then complete the enrollment below

Week 1 (July 5-9) Free to be, You & Me! $ 255.00 CAD

Campers will enjoy getting to know each other while engaging in team building activities and icebreaker games. This week is all about teamwork, making friends, building confidence and coming together as one. Creativity will also come alive this week while campers participate in multiple art and crazy crafting experiences.

T-Shirt Size

Week 2 (July 12-16) - Sassy Scientists! $ 255.00 CAD

This week is all about crazy science experiments. Campers will engage in activities that will stimulate the mind and spark curiosity such as volcanic eruptions, bubble concoctions, messy science, ice and water experiments and chemical reactions.

Week 3 (July 19-23) Groovy Chefs! $ 255.00 CAD

Campers will create their own culinary masterpieces everyday of this exciting week as well as participate in a final "cook off" on their last day! Recipe books will come home at the end of this delicious week!

Week 5 (August 3-6) Cheerleading Week! $ 230.00 CAD

This week is all about team spirit! We will visit with a cheer leading instructor who will coach us to create our own cheers and cheer leading dance routines. Campers will enjoy a cheer leading movie along with creating their own cheer leading crafts to bring home. GO!! Butterfly Campers GO!!

Week 6 (August 9-13) Water & Wellness Week! $ 255.00 CAD

Get ready to participate in our water extravaganza week where campers will challenge each other to different water games, competitions and enjoy all things water! This week will also include a visit to the local splash pad. Prepared to get SOAKED! Campers will also meet a yoga instructor and participate in a yoga class, learn to Zumba to the music and take a fun taekwondo class!

Week 7 (August 16-20) Fashion Show Frenzy $ 255.00 CAD

This week is all about fashion and girl power! Campers will work together to plan, organize and implement their own fashion show. Campers will make their own fashionable jewelry and accessories to wear in their fashion show finale. Campers will enjoy a fun spa day using their own homemade facials, and give each other simple manicures and pedicures!

Week 8 (August 23-27) Van Gogh Girls - Art Extreme $ 255.00 CAD

In addition to girl power activities, camp games, water fun and girl time, our van Gogh girls will feel like true artists while they experience painting on canvas, sculpture, vinyl art, abstract art, bead art, stamping and card making. Campers will also create their own virtual art gallery that their amazing masterpieces will be showcased in for all to see at the end of this special week. When it comes to fun and art, anything goes!

T-Shirt

Week 9 (August 30- September 3) Nature Survival & Back To School Slumber Party Sleep Over Experience $ 360.00 CAD

Campers will learn all about nature and simple survival techniques during this fun week! Shelter building, tent pitching, orienteering, animal tracking, compass use, diy survival kits and survival knots will be explored. What an exciting way to end the summer with an overnight experience right inside our own camp building where campers will tell stories, enjoy a bbq dinner and bake a special dessert, then enjoy a movie and sleep over! Campers will enjoy a healthy breakfast the next morning before being picked up. What a great way to spend the last week of summer celebrating with their new found friends at Butterfly Camp.

One Time Registration Fee $ 40.00 CAD

This fee pays for administrative costs associated with your child's enrollment as well as a small portion of the online payment processing fees.

Total $ 0.00 CAD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

CHILD INFORMATION:
Camper's Name *

First Name Last Name
Birth Date *

Month Day Year
Age as of June 30, 2021 *
Grade *
Camper's Home Address *

Street Address

Street Address Line 2

City Province

Postal Code
Home Phone Number *
Who does the camper live with?

Both Parents Father Mother Grandparent(s) Foster Parent(s)
Are there any access orders/agreements, court orders or custody documents regarding this camper?

Yes No
Previous school camper attended:
Sibling #1 Information

Name Age School
Sibling #2 Information

Name Age School
Sibling #3 Information

Name Age School
Language(s) Spoken at Home *
PARENT/GUARDIAN INFORMATION:
Parent/Guardian #1 Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City Province

Postal Code Country
Home Phone Number *

Area Code Phone Number
Mobile Phone Number *
Occupation *
Name of Work Place *
Work Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone Number *

Area Code Phone Number
E-mail *
Does parent/guardian #2 have the same address as parent/guardian #1? *

Yes No There is no second parent/guardian
Parent/Guardian #2 Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number *

Area Code Phone Number
Mobile Phone Number *
Occupation *
Name of Work Place *
Work Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone Number *

Area Code Phone Number
E-mail *
example@example.com
Alternate Emergency & Child Release Information

Please provide two alternate adults (other than parents/guardians listed above) that can be contacted in an emergency and that you permit your child to be released to if needed.
Emergency Alternate Adult #1 *

First Name Last Name
Relation to child *
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number *

Area Code Phone Number
Work Phone Number *

Area Code Phone Number
My child can be released to this person *

yes no
Emergency Alternate Adult #2 *

First Name Last Name
Relation to child *
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number *

Area Code Phone Number
Work Phone Number *

Area Code Phone Number
My child can be released to this person *

yes no
MEDICAL INFORMATION
Physician Name *

First Name Last Name
Physician Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Health Card Number *
Does this camper have any physical limitations that we need to be aware of? *

yes no
If yes, please provide details
Are there any other social, emotional, physical or medical details that may be helpful for us to know? *
If there is no additional information please indicate n/a
Please list all allergies/medical concerns/special needs. (Please indicate "none" if none are present) *
(Please describe/if none, please indicate with "none")
Does this camper require an Epi-pen? *

yes no
If yes, please provide details
Please book an appointment to discuss your child's anaphylaxis emergency plan
Does this child take medications on a regular basis? *

yes no
If yes, please provide details
Does your child currently have an IEP or an ISP? *

Yes No
What is your child's diagnosis?
Please upload a copy of your child's IEP or ISP

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Please upload your child's most current immunization record(s) or signed medical exemption certificate *

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History of Communicable Diseases: Please indicate if this child has had any of the following: *

Chicken Pox Whooping Cough Mumps (German Measles) Rubella Measles Hepatitis B None
Please indicate any additional information regarding skin disorders, sight and/or hearing difficulties. (Please indicate "none" if none are present) *
Please indicate any food restrictions (allergy/religious) or food sensitivities that we should be aware of. (Please indicate "none" if none are present) *
Please click here to submit your child's photo for our reference *
I give my child permission to apply the following topical products to themself during their time at Butterfly Camp. All products will be provided only by me for my child's use. *

Sunscreen Insect Repellent None
Parent/Caregiver Signature *

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Service Contract and Policy Agreement

Please complete by signing on the line provided for each agreement. By signing each statement you are agreeing to the terms of our service.
I have read through The Kinder Garden's camp guide and Covid Response Plan and understand and agree to comply with all rules, policies and procedures stated within. (Please sign below) *

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I understand that I am responsible for a "late pick up fee" of $20 per 15 minutes or part thereof in the event that I arrive or leave the building after the posted closing time. This payment is due upon arrival on my child's next day or attendance and is to be paid in cash to the educator who stayed late. (Please sign below) *

Clear
I understand that my child will not be released to anyone other than the people listed on my child's enrollment forms under Emergency Contacts who I have indicated that my child may be released to. It is my responsibility to inform staff when an emergency person will be picking my child up. My emergency people are required to present government issued identification to staff at the time of pick up. (Please sign below) *

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I understand and agree that I am responsible for full payment of my child's scheduled days at The Kinder Garden Children's Centre and that I will be charged a fee of $60 for payments that are returned from my financial institution. I also understand that there is no fee exemption due to illness, weather, vacation, absence, holiday closures or termination of my child's service by The Kinder Garden as outlined in the Family Handbook. (Please sign below) *

Clear
I have read through the illness/sick policy and have a clear understanding of what is expected. I understand that for Health and Safety reasons I cannot knowingly send my child to The Kinder Garden without disclosure of any known medical conditions, illness, fever and/or allergy information and doing so may result in my child's immediate termination from their program. (Please sign below) *

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Media Consent: Please select one or more to indicate your consent regarding how your child's art work and photos may be used by The Kinder Garden Children's Centre. *

I give permission to The Kinder Garden to photograph, audio record and/or video tape my child for the purpose of professional development within the organization. I give permission to The Kinder Garden to display my child's work including art, class photos and individual photos within the centre and in the classroom learning story binders. I give permission to The Kinder Garden to post photos of my child engaging with their educators and peers on the organizations website and/or social media account as a way to share how children learn with our local community.
Parent Consent Signature *

Clear
Community Walks: Often we like to include walks in and around our community as part of our program plan in order to continue and complement our teachings of the seasons, make observations of nature and to provide variety each day. Staff to child ratios will not be reduced during times that the children are outside in the playground or off premises as regulated by the Child Care and Early Years Act and The Ministry of Education. Parents will be notified when educators plan to take children into the community .
I First Name* Last Name* give The Kinder Garden Children's Centre permission to take my child: First Name* Last Name* on walks within the community for educational and outdoor variety purposes. I understand that the children will always be walking with qualified staff members of The Kinder Garden. Date*
Parent Consent Signature *

Clear
Personal Information: I hereby consent to the collection, use and disclosure of my child's information by The Kinder Garden for the purposes of providing camp and/or child care services to my child enrolled in centre programs. I understand that the centre protects the privacy of all personal information in its possession in compliance with prevailing privacy legislation. (Please sign below) *

Clear
How did you hear about us! *

Billboard Advertisement Facebook Mobile Sign Advertising Word of Mouth Google Search
Terms and Conditions *
Signature
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Butterfly Camp Registration

Choose Your Adventure!

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

Alternate Emergency & Child Release Information

MEDICAL INFORMATION

Service Contract and Policy Agreement