EKTA Camp Registration form

EKTA Camp Registration

Express yourself * Know yourself * Trust yourself * Accept yourself
Student Information
Student's Name

First Name Last Name
Birth Date

Month Day Year
Health Card Number
Grade
Gender

Female Male Other
Address

Street Address

City Province

Postal Code
Parent/Guardian Information
Parent #1

First Name Last Name
Home Number
Cell Number
E-mail
example@example.com
Parent #2

First Name Last Name
Home Number
Cell Number
E-mail
example@example.com
Who is authorized to pick up your child?
Emergency Information
Emergency Contact's Name

First Name Last Name
Relationship
Phone Number
Alt. Phone Number
Health History/Conditions
Does the student have any allergies, chronic illness, mental health concerns or medical conditions? If yes, please describe.
Does your child have any exceptionalities or special needs? If so, please describe.
Please list medications your child takes on a regular basis.
Please list medications we can administer to your child.
Authorization to administer prescription medicine (including Epi-pen):

yes no
Consent to share health information with health professionals:

yes no
About Your Child

Help us get to know your child.
Please describe your child's strengths (personality traits, skills, passions).
Please share your child's challenges or struggles.
What activities does your child love to do?
Please send the $175 deposit via e-transfer to the following email to hold your child's space:

ektaschoolorangeville@gmail.com
Do we have permission to take photos for marketing purposes?

yes no

Acknowledgement of Cancellation Policy

I understand that the deposit is non-refundable.

I understand there is no refund for days missed due to my child's absence as a result of illness or other reasons.

If the program needs to be cancelled on a given day, that day will be fully refunded.
Do you agree to the cancellation policy?

Yes No
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by EKTA during the selected program. In exchange for the acceptance of said child’s candidacy by EKTA, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless EKTA and all its facilitators from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected program sessions.

In case of injury to said child, I hereby waive all claims against EKTA including all facilitators, all participants, and, if applicable, owners and lessors of premises used to conduct the event.
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

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EKTA Camp Registration

About Your Child

Please send the $175 deposit via e-transfer to the following email to hold your child's space: