Family Relief Summer Camp Registration 2019

*Indicates a required field

Camper Information

*Name of Camper:

*DOB:

*Names of Parents/Guardians :

*Address: *Postal Code: *Cell Phone: *Child lives with : *Family Doctor:

*City: *Home Phone: *Work Phone: *If Other Specify: *Health Card Number:

*Disability/Diagnosis :

*E-Mail Address:

Emergency Contact

*Name of Contact/Relationship (to child) :

*Address:

*Home Phone:

*Cell Phone:

*Work Phone:

Medical Information

*Allergies (food, medication, environmental, etc..) :

If yes please specify:

*Behaviours:

Aggression

Running away

Tantrums

Withdrawn behaviour

Self Injury

*Does your child have a behaviour plan?:

*Will it be sent with him/her?:

Are there any triggers? Is there a plan in place to support your child? Safety concerns? :

*Asthma:

Does he/she require an inhaler? :

Will it be sent with him/her?:

*Seizures:

Frequency:

Triggers:

*Toileting Does your camper have a toileting routine?:

If yes , please explain in detail:

*Does the camper wear pull-ups/diapers?:

*Medication:

If yes, please complete the following section:

Name of Medication and Dosage:

Purpose of Medication :

Dispensing Instructions:

Name of Medication and Dosage:

Purpose of Medication:

Dispensing Instructions:

ADMINISTRATION OF MEDICATION CONSENT

I, (Parent or Guardian Name):

give my permission for the Director or Assistant Director to administer :

to (Camper):

as directed by prescribing physician, Dr.:

Please check the box and Enter your Full Name to indicate your consent for Administration of Medication(s)

Acknowledge Consent

Full Name:

Date (YYYY-MM-DD):

DAY CAMP REGISTRATION 2018

*Please Select the Camp your Child will be attending:

*Will your child-youth require a one to one worker or additional staffing support?:

*This Summer, our day camp is being offered in 6 weekly sessions only. Please select the weeks your child would like to attend.

Week 1 July 8 - 12

Week 2 July 15 - 19

Week 3 July 22 - 26

Week 4 July 29 - Aug 2

Week 5 Aug 6 - 9

Week 6 Aug 12 - 16

*Please indicate the days your Child will be attending for each week selected above:

PLEASE NOTE DEADLINE FOR CAMP REGISTRATION IS FRIDAY May 15, 2019.
We will not be able to guarantee a space after this date.
We need your package and payment before we can register your child…….

PLEASE CONTACT YOUR CASEWORKER IF YOU HAVE ANY QUESTIONS…

Rates for Camp:
Day camp $65 per day
Youth camp $65 per day
Kids just like me $135
Au-some camp $135
1:1 worker $135 per day

Transportation Rates
In Town Trips $5.00 one way
Out of town trips $10.00 one way
Bus transportation $10 each way

*Additional fees apply to non-LCP clients

*I would like to purchase a camp t-shirt for my child, from my child's LCP account, $20:

*Communication My child is:

If non-verbal… does he/she use an alternative method of communication :

PEC symbols

Gestures

Sign Language

iPad

Blissymbolics

Do they use Proloquo2go?:

*Please provide the camp with any communication devices.

Eating and Foods

General response to food (including preferences and any eating difficulties):

Special Diet (if any) :

Any eating/feeding programs you would like to be followed throughout the day at camp…:

*Activity Level:

What activities does the camper enjoy?:

What activities does the camper not enjoy?:

Please indicate his/her swimming capabilities :

Additional Information that would help our staff care for your child better :

Transportation Information

There is an additional cost for transportation each day to and from camp…. if you could drop off child it would be greatly appreciated.

*Parents able to drop and pick up camper:

PLEASE NOTE
Your child will NOT be permitted to leave camp alone unless you call or send a note.

If your child requires a car seat or booster seat it must be provided by the family

I, (Parent or Guardian Name):

authorize my child:

to travel to/from camp activities in the cars, bus or other transportation vehicles with L.C.P. staff.

These arrangements will be made by Lanark Community Programs.

Please check the box and Enter your Full Name to indicate your consent for Transportation.

Acknowledge Consent

Full Name:

Date (YYYY-MM-DD):

Consent to be photographed

I,:

to allow (Camper):

to be photographed.

I grant permission to the above mentioned summer camp and Lanark Community Programs and its’ employees to take and use (including publish) for the purposes of instructions, promotion, FR website fundraising similiar purposes photographs, website, facebook ,films and videos of the of the above.

Please check the box and Enter your Full Name to indicate your consent to be photographed.

Acknowledge Consent

Full Name:

Date (YYYY-MM-DD):

***Our Facebook page and website are accessible to the public www.frprograms.weebly.com***

CONSENT TO RELEASE INFORMATION

I hereby authorize the Director and/or Assistant Director of (Name of camp program):

to obtain information or to consult with the following organizations and/or individuals listed below regarding(camper):

I understand that any information collected or shared will remain confidential and be used for the sole benefit of the child.

Name of Organization Contact Name and Phone

Oragnizations & Contact information:

Please check the box and Enter your Full Name to indicate your consent to Release Information.

Acknowledge Consent

Full Name:

Date (YYYY-MM-DD):

CONDITION OF ENROLMENT FORM

In order to participate in the Camp Program you agree to be bound by the following conditions:

The Supervisor at his/her sole discretion reserves the right to dismiss a child from the program when he/she deem this to be in the best interest of either the child, the children, or the program itself. Following contact from the Camp Director or Assistant Director, it is the responsibility of the parent/guardian, or supporting organization, to quickly seek transportation and arrangements to remove the participant from camp.
The above mentioned Day Camp and Lanark Community Programs, or its agents, will NOT be held responsible for any accidents, injuries, losses or damages that may occur as a result of participant involvement in the above mentioned Day Camp. These activities may include community outings, bus trips and swimming. As a parent/guardian, I will be notified of these trips or outings upon arrival to camp or through the camp=s weekly newsletter.

I have read and agree to all the conditions stated in the Conditions of Enrolment for my child to attend the

*(Name of Day Camp Program):

Please Check the box and Enter your Full Name to indicate you have Read and agree to all of the conditions of Enrollment for your Child to attend the Day Camp Program.

*Acknowledge Agreement

*Full Name:

*Date (YYYY-MM-DD):