School Break Camps – Waitlist 2022/2023

Program Options*

Select All
Winter Break - December 28-30, 2022
Second Winter Break - January 3-6, 2023
Teachers' Convention - February 27 - March 3, 2023
Easter Break - April 10-14, 2023

Child's Information

Child's Name*

First Last

Child's Address*

Street Address City Postal Code

Child's Birthdate*

Child's Birthdate

School Attending

Grade

*

Gender

Mother / Guardian Contact Information

Mother / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Mother / Guardian Email

Email

Father / Guardian Contact Information

Father / Guardian*

Name Cell# Work#

Child's Address*

Street Address City Postal Code

Father / Guardian Email*

Email

Parent/Guardian with legal custody*

*If there is a custody order please include a copy with your registration

Emergency Contact Information

Emergency Contact (Cannot be Mother or Father, must have a local address)

Emergency Contact Name*

Name Cell# Work#

Emergency Contact Address*

Emergency Contact Address

Emergency Contact Address*

Street Address Address Line 2 City Postal Code

List of People allowed to Pick up your child

Are there any immediate family members that should be denied phone calls with your child?

Additional people who may pick up your child:

Who will pick up child within 30 minutes if they are ill. (Mother, Father, or Emergency Contact)*

Medication Required (epi pen, puffer, etc.)?*

Yes
No

Medication Required Type

Relevant Health information (Medical Condition (s))?*

Yes
No

List Medical Condition(s):

Does your child have any pre-existing conditions that may present as influenza like symptoms? Ex: Allergies, chronic cough, etc*

Yes
No

List pre-existing Condition(s):

Is Your Child Immunized?*

Yes
No

Allergies?*

Yes
No

Allergies please list

Any pre-existing conditions that may present as COVID like symptoms?*

Yes
No

Inclusive care needed? (If Yes, interview required)*

Yes
No

Please describe child's inclusive care condition/needs

Dietary restrictions please List

Cultural Background:*

Cultural Background:

Please list any other relevant Information:

I agree:*

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School Break Camps – Waitlist 2022/2023

School Break Waitlist 2022-2023

Child's Information

Mother / Guardian Contact Information

Father / Guardian Contact Information

Emergency Contact Information