Summer Camp (School Age) Registration Form

Current Grade:*

Child's Full *LEGAL* Name:*

First NameLast Name

Preferred Name (optional):

MaleFemale

Date of Birth:*

MM/DD/YYYY

Health Card No. (OHIP or Insurance):*

If OHIP, please follow format: ####-####-###-**

Home Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code (Format: "M1T 2M2")

Primary No.*

Format: (000) 000-0000.

Language usually spoken at home:*

YesNo

If Yes, please describe in detail (i.e., anaphylaxis?):

How does your child react to stress and illness?*

For example: Fatigue, cries, becomes quiet, does not communicate, outbursts, etc.

Does your child have any challenging behaviours?*

For example: Runs away, may hurt others and/or themselves, screaming, inappropriate language, outbursts, etc.

How do you discipline your child?*

As we want this to be a collaborative effort between the home and camp environment, this information will help our Summer Staff better care for your child.

Any strong interests/likes?*

Any strong dislikes and/or fears?*

Any major traumas?*

Additional information:*

Does your child have any conditions and/or official diagnoses that we should be aware of? Please put N/A if none.

Parent/Guardian #1 Name:*

Relationship to Child:*

Cell No.*

Format: (000) 000-0000.

Occupation:

Business Address:

Street Address

Street Address Line 2

Business No.

Format: (000) 000-0000.

Parent/Guardian #2 Name:*

Relationship to Child:*

Cell No.*

Format: (000) 000-0000.

Occupation:

Business Address:

Street Address

Street Address Line 2

Business No.

Format: (000) 000-0000.

Doctor's Name:*

Please enter your child's doctor's FULL NAME.

Phone No.*

Format: (000) 000-0000.

Office Address:*

Street Address

Street Address Line 2

CityProvince

Postal Code (Format: "M1T 2M2")

YesNoSeparated

If separated, please describe the visiting rights:

Mother's Address:

Please follow format: "2230 Birchmount Rd, Scabrorough ON, M1T 2M2"

Street Address Line 2

Father's Address:

Please follow format: "2230 Birchmount Rd, Scabrorough ON, M1T 2M2"

Street Address Line 2

Email Address for receiving daycare updates and information:*

Preferred Name(s) for Official Tax Receipts:*

*Not the child's name

GOOD SHEPHERD DAY CARE CENTRE

Summer Camp (School Age) Registration Form

Enrollment Information

Child's Information

Family Information

Emergency Contacts & Pick-Up Authorization

Primary Emergency Contact

Secondary Emergency Contact

OTHER THAN PARENTS:

Additional Emergency Contact #1

Additional Emergency Contact #2