January 2026 PA Day Camp Registration Form

ICAC January 2026 PA Day Camp Registration Form

Child's Name*

Age*

Birthdate*

Date

Address*

Address

Street Address Line 2

Postal Code

Parent/Guardian's Name(s)*

Home Phone

Cell Phone*

Work No

Email Address*

example@example.com

Emergency Contact: In the event the parent/caregiver(s) cannot be reached, please list additional contacts.

Full Name (Person #1)*

Relationship (Person #1)*

Phone Number (Person #1)*

Full Name (Person #2)*

Relationship (Person #2)*

Phone Number (Person #2)*

Sign-In/Out: Please list ALL people authorized to sign your child in and out of day camp. Please note that individuals listed will be required to show photo ID at time of pick up.

Full Name (Person #1)*

Relationship (Person #1)*

Phone Number (Person #1)*

Full Name (Person #2)

Relationship (Person #2)

Phone Number (Person #2)

Registration Date: Please select which PA Day(s) you will be registering your child for.

Friday, January 30, 2026 - $45

I permit ICAC to take photos/videos of my child for social media and promotional purposes. Please be advised that children will not be named or tagged in photos/videos.*

YesNo

Medical Information: Please list any medical conditions we should be made aware of this includes usage of an Epi-pen, allergies, physical disabilities, learning disabilities, emotional difficulties, or anything special we should know about your child. If your child has an allergy please list signs symptoms and treatment.

Will your child require medication during camp?*

YesNo

If yes, please choose the preferred option of administration:

My child can administer their own medication as described below.I permit the ICAC Camp staff to administer my child's medication as described below.

Medication #1: blanks
Expiry (Medication #1): blank
Dose Administered (Medication #1): blank
Time Administered (Medication #1): blank

Medication #2: blanks
Expiry (Medication #2): blank
Dose Administered (Medication #2): blank
Time Administered (Medication #2): blank

Medication #3: blanks
Expiry (Medication #3): blank
Dose Administered (Medication #3): blank
Time Administered (Medication #3): blank

Medication (including Epi-pens) must be submitted to our office in its original prescribed bottle with child's name. The medication administration chart above must match the prescription label.

Waiver (Please read carefully): I permit my child to participate in all activities offered in the program. In the event of an accident or illness affecting my child, I consent to have the Ingersoll Creative Arts Centre staff authorize any necessary procedures, including admission to the hospital, as may be deemed essential for the care and well-being of the participant. Such action is to be taken only when immediate contact with the parent/guardian or emergency contact(s) cannot be made. I understand that, to be eligible for a refund, 2 weeks notice will be required to cancel care. I have read, understand, and accept the Ingersoll Creative Arts Camp Program's policies as described in this waiver, and I have read and understand all information in the provided information packet.

Signature of Parent/Guardian*

Date*

Date