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CAMP PROMISE AFTER SCHOOL PROGRAM APPLICATION FORMPROGRAM
NAMECAMP PROMISE AFTER SCHOOL PROGRAM Fall 2017- Spring 2018
Program Bethel Community ChurchLocation128 St Vincent Street Barrie, ON L4M 3Y8
Program Time3:30pm –5:30pm Wednesdays, Thursdays, Fridays
Start Date Wednesday September 13, 2017 End Date: Thursday May 17, 2018 Cost Free
Meet: At Program Location above OR We Pick Up the children at Codrington and Oakley Park Schools at 3:20pm.
Contact Person Camp Director: Tracy Robinson
PLEASE BRING HOME WORK AND ANY COMMUNICATION BOOK USED WITH CLASSROOM TEACHER
APPLICATIONSCANNOTBEACCEPTEDIFINCOMPLETE.PRINTCLEARLYINBLUEORBLACKINK
CHILD/YOUTHINFORMATION
LastName FirstName M.I.
Date ofBirth D M Y Age Gender MALE FEMALE
Health Card Number(Required)
Medical Conditions orAllergies
Special Needs (i.e.ADD/ADHD, Autism, LearningDisabilities)Name ofSchool Grade Name ofTeacher
PARENT/GUARDIANINFORMATION
LastName FirstName M.I.
StreetAddress Apartment/Unit#
City Province PostalCode
HomePhone ( ) E-mailAddress
CellPhone ( ) OtherPhone ( )
EMERGENCYCONTACT
LastName FirstName M.I.
HomePhone ( ) CellPhone ( ) Relationshipto child/youth
AlternateContact
HomePhone ( ) CellPhone ( ) Relationshipto child/youth
ACKNOWLEDGEMENTIherebygrantpermission formychildtoparticipate inalltheactivitiesof thisprogram (whichmayincludeoutingsduringprogram hours)andrelease Camp Promise and staff from any and all liability, claims, demands, personal injury, sickness, death, as well as property damage and expenses ofanynaturewhatsoever,whichmaybeincurredbythechildparticipant.FurtherIgrantpermissiontoCamp Promisestafftoauthorizemedicalpersonnelto carryoutanyemergencyprocedureonmychildinthe casethatI,ormyemergencycontact,cannotbereached atthetimeoftheincident.Inaddition,I understandthatphotographs/videoofmychildtakenduringprogrammaybeusedforpromotionalmaterial.I havereadandunderstoodthiswaiver.
Parent/GuardianSignature Date
camppromise@bethelbarrie.ca 128 St. Vincent Street Barrie, ON L4M 3Y8 Tel:705-726-9778 Fax:705-722-5082
RegisteredwiththeCanadaRevenueAgencyRegistrationNo.128793049RR0001
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