Easter Camp

Child's Information

Participant Name*

First NameLast Name

Birth Date*

MonthDayYear

Alberta Health Care Number*

2nd Participants Name

First NameLast Name

Birth Date

MonthDayYear

Alberta Health Care Number

3rd Participants Name

First NameLast Name

Birth Date

MonthDayYear

Alberta Health Care Number

Parent/Guardian Information

Parent / Guardian 1*

First NameLast Name

Parent 1 Cell Number*

Area CodePhone Number

Parent / Guardian 2

First NameLast Name

Parent 2 Cell Number

Area CodePhone Number

Home Number

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name (not a parent)*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Are the above people listed authorised to pick up your child*

YESNO

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Does the child have an medication? If yes, please explain dosage and any instructions.

Additional Notes

Easter Day Camp (Select number of participants)

The Park Cancelation and Withdrawal Policies

If a child is to be withdrawn from The Park Camp or if The Park has to close for reasons out of their control during the current week of camp, no refunds will be issued.

Medical Release and Authorization

EMERGENCY RELEASE: Consent to Emergency First Aid & Transportation:

Permission is granted to the 'The Park' and its affiliates including Directors, Leaders, and Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

I hereby give permission that my child may be given emergency treatment by a staff member certified in First Aid at The Park Ltd. I also give permission for my child to be transported by ambulance, to an emergency centre for treatment, and agree to hold The Park Ltd. and its employees and directors harmless. The Park Ltd. will not be responsible for any incident that may occur as a result of false, misleading or missed information that is given or omitted at the time of enrolment or any time thereafter.

Permission is hereby granted to the attending physician to proceed with any medical or surgical treatment, x-ray and examination.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

My Products

Registration Fee$15.00CAD

Non-Refundable

Subtotal $0.00CADTax $0.00CADTotal $0.00CAD

Credit Card

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Date*

Date