Day Camp Registration Form
These forms are required for your child to attend camp.
Camper's Information
Camper Name
*
Nickname
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Age (at camp)
*
Please Select
4
5
6
7
8
9
10
11
12
Associated Cottage Site Number
*
Weeks Interested
*
Camper Swimming Ability
*
Non-Swimmer
Beginner Swimmer (can swim on front 20ft without flotation)
Advanced Swimmer (can pass swim test)
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
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Parents' Information
Parent/Guardian 1
Parent/Guardian 1
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Format: (000) 000-0000.
Home Phone
*
Format: (000) 000-0000.
Where would you like to be reached while your child is at camp?
*
Cell Phone
Home Phone
Parent/Guardian 2
Parent/Guardian 2
*
First Name
Last Name
Relationship to Child
*
E-mail
*
Cell Phone
*
Format: (000) 000-0000.
Home Phone
*
Format: (000) 000-0000.
Where would parent/guardian 2 like to be reached while your child is at camp?
Cell Phone
Home Phone
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you.
Emergency Contact
Full Name
*
First Name
Last Name
Primary Phone Number
*
Format: (000) 000-0000.
Secondary Phone Number
*
Format: (000) 000-0000.
Relationship to Child
*
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Medical / Health Information
Is the Camper up-to-date on all immunizations?
*
Yes
No
Does your child have any food, medication or environmental allergies?
*
Yes
No
Allergies? Check all that apply
*
Food
Medication
Environmental
Please list and explain any allergies
*
0/150
Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?
*
Yes
No
Does your child have a special health or medical condition?
*
Yes
No
Please explain
*
0/150
Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?
*
Yes
No
Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
*
Yes
No
Please explain
*
0/150
If yes, does this medication, food supplement, or medical food need to be administered at the day camp?
*
Yes
No
List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.
*
0/200
List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions.
*
0/200
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Payment and Statement of Understanding
Number of Weeks:
Please select the number of weeks you are signing your child up for:
*
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( X )
One week
$
375.00
CAD
Two weeks
$
750.00
CAD
Three Weeks
$
1,125.00
CAD
Four Weeks
$
1,500.00
CAD
Five Weeks
$
1,875.00
CAD
Six Weeks
$
2,250.00
CAD
Seven Weeks
$
2,625.00
CAD
Total
$
0.00
CAD
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please select the T-Shirt size for your child:
*
Youth Small
Youth Medium
Youth Large
Youth XL
Adult Small
Adult Medium
Adult Large
The Go Home Day Camp has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type first and last name above to consent
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
Date Picker Icon
Camp Director Name and Contact Info
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