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Lumby Summer Day Camp Registration

- Step 1 of 7

Child's Name: *

First

Last

Date of Birth: *

Gender: *

Male
Female
Other

Age: *

Grade: *

(In September)

Child lives with: *

Parents
Mother
Parent
Guardian

Mailing Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent/Guardian #1: *

Primary Phone Number: *

Secondary Phone Number:

Work Phone:

Place of Employment:

Email Address: *

Add another Parent/Guardian? *

Yes
No

Parent/Guardian #2: *

Primary Phone Number: *

Secondary Phone Number:

Work Phone Number:

Place of Employment:

Email Address: *

Does your child identify as an Indigenous Person or other racialized community? *

Yes
No

Which community: *

First Nations
Inuit
Metis
Other

Please specify:

Child Access

Can an adult, other than the parent(s)/guardian(s), pick up your child? *

Yes
No

Who? *

I give consent to Kid’s Space Summer Day Camp Program to release my child to someone other than the parent/guardian. I understand the staff will not release a child unless the parents/guardians have notified staff of who can pick up the child and until they have seen proper identification. *

Please type your initials in the box above

Is there any person(s) who CANNOT access your child? *

Yes
No

Person(s) who CANNOT access your child: *

Provide Custody Order(s) if any- REQUIRED by Licensing

Emergency Contacts

Name: *

First

Last

Friends or relatives who are NOT living in the same house as child (At least 1 is REQUIRED by Licensing)

Relationship to child: *

Primary Phone Number: *

Secondary Phone Number:

Work Phone Number:

Add another emergency contact? *

Yes
No

Name *

First

Last

Friends or relatives who are NOT living in the same house as child (At least 1 is REQUIRED by Licensing

Relationship to child: *

Primary Phone Number: *

Secondary Phone Number:

Work Phone Number:

I, *

First

Last

Give permission to the above mentioned adults to assume responsibility for my child in the event of an emergency

Health History

Doctor:

First

Last

Doctor's Phone:

Care Card #: *

Immunizations up to date? *

Yes
No

Allergies/Asthma? *

Yes
No

Allergies/Asthma Form

Child's Name:

First

Last

Phone Number:

Layout

Allergies/Triggers *

Reactions/Symptoms *

Type (food, drug, environmental) *

Prevention and/or Treatment *

Medication:

Layout

Name of medication: *

Frequency (ex. daily; as needed): *

Dose: *

What to do if a severe reaction occurs: *

Other information:

Parent's Signature - Enter your name below: *

First

Last

Date: *

Special Needs/Medical Disability? *

Yes
No

Special Needs/Long-term Condition Form

Child's Name: *

First

Last

Phone Number: *

Layout

Condition(s) name(s): *

Name of/information on condition(s)

Condition(s) name(s):

Name of/information on condition(s)

Symptoms: *

Symptoms/Problems to watch for

Symptoms:

Symptoms/Problems to watch for

Action Required: *

Indicate actions required here

Action Required:

Indicate actions required here

Add more conditions? *

Yes
No

Layout (copy)

Condition(s) name(s):

Name of/information on condition(s)

Condition(s) name(s):

Name of/information on condition(s)

Symptoms:

Symptoms/Problems to watch for

Symptoms:

Symptoms/Problems to watch for

Action Required:

Indicate actions required here

Action Required:

Indicate actions required here

Special childcare programming requirements/instructions for staff:

Other information:

Parent's Signature - Enter your name below: *

First

Last

Date: *

Is there Medication staff will need to give your child? *

Yes
No

Medication Consent and Record Form

Child's Name: *

First

Last

Phone Number:

Layout

Type: *

Type 2 (first table)

Type 3 (first table)

How Many Times per Day? *

How Many Times per Day?

How Many Times per Day?

Layout

Type *

Type 2 (second table)

Type 3 (second table)

Type 4 (second table)

Dosage *

Dosage 2:

Dosage 3:

Dosage 4:

Date/Time *

Date/Time 2:

Date/Time 3:

Date/Time 4:

Given By *

Given By 2:

Given By 3:

Given By 4:

It is the responsibility of the parent to notify the Program Staff of ANY changes in medication or dosage of medication. All medication MUST be in its ORIGINAL container and clearly marked.

I give permission for staff members of the Lumby Summer Day Camp/Before School program and After School Program to administer the medication.

Parent's Signature - Enter your name below: *

First

Last

Date: *

REMARKS:

Does your child have a Behaviour Plan in place? *

Yes
No

Special Comments/Instructions

Photo and Description

Photo: *

Hard copy
Digital copy

Photo Upload:

Click or drag a file to this area to upload.

Layout

Height: *

Weight: *

Eye Color: *

Hair Color: *

Identifying Marks (if any):

Will you be applying for Subsidy *

Yes
No

Lumby Summer Day Camp will operate July 11th to August 25 (closed Aug. 7th for the stat). Please provide your requested days of attendance for July and August. Your child's (ren's) registration is not complete until your days are confirmed by an email from the office and payment is received. *

Consent

1. In case of an emergency, I hereby give permission to the staff to call a doctor or ambulance in the event of an accident or illness involving my child and to release my child to someone other than the parent. I will be responsible for the costs *

Please type your initials in the box above

2. I give my consent for my child to take part in field trips, local and off-site, under the supervision of the staff and to be transported by buses when appropriate. *

Please type your initials in the box above

3. With my signature/initials below I grant permission for my child(ren) whose name(s) are listed below may be photographed at the programs and I understand that these photographs may be used in promoting our organization and services or by program funders, either in print or on the Internet. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment. I understand that there will be no payment for me or my child’s participation in this release.

Please type your initials in the box above

4. My child’s immunization is up to date, and if not, I understand that in the case of an outbreak my child(ren) will not be permitted at the program until immunizations forms are brought in *

Please type your initials in the box above

5. Lumby Summer Day Camp Program reserves the right to dismiss any attendee for inappropriate conduct, at the discretion of the staff and administration. *

Please type your initials in the box above

6. There are no refunds, nor are there carry-overs from previous or present camps *

Please type your initials in the box above

This is a prepaid program. Your registration is not complete until payment and schedule has been received *

Please type your initials in the box above

Please note that once you have registered and pre-paid for your child(ren)’s spot, this money is not refundable for absences due to illness or change of plans *

Please type your initials in the box above

I understand that if I send my child with a lifejacket, they will wear it at all times in and around the water. *

Please type your initials in the box above

I give permission to the staff to apply sunscreen on my child whenever it is needed. *

Please type your initials in the box above

7. I have read the entire registration form and understand the above information. I have initialed all that I agree to. All information on this form is correct, to the best of my knowledge *

Please type your initials in the box above

Parent's Signature - Enter your name below: *

First

Last

Date: *

Contact us: Box 661, 2114 Shuswap Ave. Lumby
P: 250 547-8866 ~ F: 250 547-6285
e: info@whitevalley.ca

©2023 Whitevalley Community Resource Centre