TOT CAMP 2023

CHILD INFORMATION

CHILDS NAME

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemaleNot specified

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

DAY CAMP WEEKS

PICK UP PERMISSION

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

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

Helpful hints/likes and dislikes

BEHAVIOR CONCERNS

short medical #

long medical #

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Earl Grey Community Centre during the selected camp.

I UNDERSTAND THAT BY COMPLETING THIS FORM, THE CITY COMMUNITY CENTRE IS COLLECTING CERTAIN INFORMATION ABOUT MY
CHILD, MYSELF AND OTHER FAMILY MEMBERS INCLUDING WHEN NECESSARY MY MANITOBA HEALTH REGISTRATION NUMBER.

I ALSO UNDERSTAND THAT THIS PERSONAL INFORMATION WILL BE USED FOR THE PURPOSE OF REGISTERING IN THE COMMUNITY
CENTRE SPORT RECREATION AND LEISURE PROGRAMS AND THAT SUCH USE SHALL INVOLVE THE DISCLOSURE OF THIS PERSONAL
INFORMATION TO THE APPROPRIATE SPORT ASSOCIATION(S) , COACH(ES), STAFF, CAMP LEADER(S) AND MANAGERS

I will follow all current all current public health rules set out for COVID -19

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.

2023 TOT Summer Camp Registration