Child/Youth Application: 2024 Summer Camp (Site Based Group Program)

Medical and Emergency Information

(If parent/guardian/caregiver can’t be reached then this person listed below is granted permission to pick up child/youth and/or authorize emergency treatment)
Name*

First NameLast Name
Relationship to Child/Youth:
Cell Number:*
Please enter a valid phone number.
Work Number:
Please enter a valid phone number.
Physician's Name:
Child/Youth's Health Card Number:
Please note any health issues/medications/allergies/food restrictions to be aware of:*
Parent/Guardian Signature is required:
I, parent/guardian/caregiver First Name* Last Name* give Big Brothers Big Sisters of the Fraser Valley permission to pursue the application of my child/youth First Name* Last Name* . I understand the agency is under no obligation to accept or assign the application and is not required to divulge the reasons for this decision. I also acknowledge that the case file is the property of the agency.

I, the parent/guardian/caregiver of the above-mentioned youth, understand that all youth/children in the program must participate in the child safety training program, Strong from the Start, prior to participating in a mentoring program.

In case of accident, illness or surgical emergency to child and if I am not immediately available for consultation and consent, I HEREBY AUTHORIZE AND DIRECT the mentors to secure proper medical or other related treatment for the child/youth. Mentors will not be responsible for transportation of my child to hospital. If I am not available to transport the child/youth the mentor has permission to call for an ambulance. All costs incurred are the responsibility of the parent/guardian/caregiver.
Signature of Parent/Guardian/Caregiver*

Clear
Date

MonthDayYear
Date

How will your child/youth be getting home from the summer day camp program? Check off which ones apply.
Someone will be picking up the child/youth

YesNo (I give the child/youth permission to walk to/from the camp)
If yes, who has your permission and will be picking up the child/youth?
Should be Empty:

Child/Youth Application

Medical and Emergency Information