Summer Camp Detailed Registration Form

Registration Form
Child's Information
APPLICATION/REGISTRATION FEE: Camp costs $160/child per week. You can choose to pay the full amount when signing up for each week your child attends or pay $80 now and pay the remainder when child starts summer camp. You will be sent an invoice via email, you can pay via e-transfer or through the invoice square portal. The remaining $80 will be required and sent via invoice the week before camp starts. E-transfers to be sent to sjones@behaviouralconnections.com Camp will run from July 2, 2024 until August 30, 2024.
Type a question

Pay Full amountPay half now ($80 for each week child attends, then remainder when child starts)
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Phone Number
Alt. Phone Number
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is your child prescribed any medications? If yes, please explain any instructions.
Canvas Summer Camp will run from July 2, 2024 until August 30, 2024. Below please indicate which week you would like your child to attend.

Note: You can pick more than one week.
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Behavioural Connections during the Canvas Summer camp. In exchange for the acceptance of said child’s candidacy by Behavioural Connections ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Behavioural Connections, and all its respective staff, agents, and representatives from any and all liability for injuries to said child.

In case of injury to said child, I hereby waive all claims against Behavioural Connections. Including all staff and affiliates, all participants, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is also granted to the Behavioural Connections, and its affiliates including Directors, Staff, and Team to provide the needed emergency/ First-Aid treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

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.
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.
Date

MonthDayYear
Date
Signature

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Registration Form

Child's Information