Child's First Name * Child's Middle Initial *

Child's Last Name * Nickname

Full Home Address *

Child's DOB *

Languages spoken at home

Physician's Name *
Physician's Address *

Phone Number *

Medical Conditions? * YesNoIf yes please explain below:

Is there anything else we should be aware of regarding your child’s health or medical history?

Allergies? *YesNo

Is an Epi-pen required? *YesNo

If yes, please explain below:

Does your child receive support at school? *
(ex. EA support) YesNo

If yes, please tell us how we can support them during their time at Summer camp?

Please use this space to tell us anything you think we should know about your camper (likes, dislikes, fears, special dietary needs, etc.)*

PARENT/GUARDIAN 1

First Name *
Last Name *
Home address *
Phone number *
2nd number
Email address *
Employer
Employer phone

PARENT/GUARDIAN 2

First Name
Last Name
Home address
Phone number
2nd number
Email address
Employer
Employer phone

CUSTODY ARRANGEMENT

Please select one of the following * Parent/Guardian 1Parent/Guardian 2BothJoint

Other:

EMERGENCY CONTACT INFORMATION (SEPARATE FROM PARENTS / GUARDIANS)

In the event that we are unable to reach the parents / guardians, the parents / guardians understand and agree that we can release their child(ren) to the persons indicated as emergency contacts listed below. Emergency contacts must be at least 16 years old.

EMERGENCY CONTACT 1

EMERGENCY CONTACT 2

AUTHORIZED PICK UP (IF SEPERATE FROM PARENTS/GUARDIANS AND EMERGENCY CONTACTS)

AUTHORIZED PICK UP 1

AUTHORIZED PICK UP 2

CAMPER SIGN IN & OUT PROCEDURES

During camper drop off and pick up please proceed to the sign in/out tables where you will initial that you have dropped off, or picked up your camper(s). Please be prepared with your ID every day upon pick up as we have many staff who may not be familiar with you. Any other authorized person on your child's pick up list must also have their ID if they are picking up. No child will be released to anyone who is not recognized and who cannot produce photo ID.

PAYMENT/CANCELLATION AND FEE POLICY

A non-refundable deposit of $50 per week of camp, per child is due within 15 days of registration confirmation. Failure to make payment will result in loss of space. This deposit will be applied to total fees owing. Invoices will be sent out once registration has been confirmed and the deposit fees of $50 per week, per child have been received. Camp fees can be paid at any time leading up to your scheduled camp month(s), however the full balance is due by the 1st of July (for July camp dates) and the 1st of August (for August camp dates). Campers will not be permitted to attend our camps if fees are not paid prior to their participation. Payment via e-transfer is preferred to finance.admin@duttonchildcare.ca or you may choose to use our debit machine located at Dutton Child Care Centre at 3 Lions Rd. in Dutton. We accept VISA, Mastercard, or American Express. Accounts not in good standing risk child care being terminated, and loss of registration privilege in the future.

Cancellation requests must be sent to finance.admin@duttonchildcare.ca at least 2 weeks prior to the affected care date(s). Such requests will receive a refund less the non-refundable deposit. Any cancellations made less than 2 weeks before the camper's scheduled week(s) will not qualify for a refund and those funds will be forfeited.

PHOTO/VIDEO CONSENT

From time to time we will take pictures and videos of the children to post in the classrooms, on our social media accounts, website or for promotional purposes (brochures, advertisements, etc.)

Please indicate below the permission granted:

CONSENT FOR WALKS AND OFF-SITE ACTIVITIES

I give permission for my child to participate in off-site walks and activities * YesNo

PERMISSION TO PROVIDE EMERGENCY MEDICAL CARE

Dutton Co-Operative Child Care will make every attempt to protect the children in our care from injury or illness. In the event of an accident or illness affecting your child, staff will provide Emergency treatment and arrange for transportation to the Hospital should it be necessary. It is understood that transportation to the Hospital will only occur when immediate contact with the undersigned cannot be made or it is deemed essential for care and well being of the child.

SWIMMING PERMISSION

A major part of our summer camp programming is going to the municipal swimming pool at least twice per week throughout the summer. Reduced ratios are adhered to in the pool. The staff will be swimming with the children and the pool will be supervised by lifeguards. Should your child require a lifejacket, you can provide your own or use one from the pool. The pool has a limited supply of lifejackets. Only Canadian approved personal floatation devices (PFDs) and lifejackets will be allowed. No water wings, puddle jumpers etc. will be permitted. For more information on this please visit the Government of Canada website for approved lifejackets and PFDs.

Please tell us the level of experience your child has with swimming (indicate swim level achieved if applicable):

Child swim level: *BeginnerIntermediateAdvanced

Will your child require a life jacket? *YesNo

PLEASE NOTE A SWIM TEST WILL BE REQUIRED IF YOUR CHILD WISHES TO SWIM IN THE DEEP END.

I,  give permission for my child,   to participate in the public swim at the public pool on designated swimming days as part of the Dutton Co-Operative Child Care Summer Camp Program. *

AUTHORIZATION FOR NON-PRESCRIPTION SKIN PRODUCTS

I authorize these family-provided non-prescription items may be applied to my child in accordance with the manufacturer’s instructions on the original container (please check off all that apply to your child) *

SunscreenLip balmInsect repellentLotions

AGREEMENT

By signing below I confirm that I have read and understand all permissions laid out in this registration form and Parent Handbook (found under the Parent Information tab, at www.duttonchildcare.ca). I have provided the Dutton Co-operative Child Care Centre Inc. with the appropriate information required for the safety and well-being of my child including any allergy, medical, and behavioural considerations.

Parent/Guardian Signature *

Date *

* By submitting this form, I accept the Dutton Child Care Centre Terms and Conditions.

* By selecting this box, I acknowledge that I have selected a contiguous full-week camp reservations.