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CAMP PROMISE AFTER SCHOOL PROGRAM APPLICATION FORMPROGRAM
NAME CAMP PROMISE AFTER SCHOOL PROGRAM Fall 2016- Spring 2017
Program Bethel Community ChurchLocation 128 St Vincent Street Barrie, ON L4M 3Y8
Program Time 3:30pm – 5:30pm Wednesdays, Thursdays & Fridays
Start Date Wednesday September 14, 2016 End Date Thursday May 18, 2017 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
APPLICATIONS CANNOT BE ACCEPTED IF INCOMPLETE. PRINT CLEARLY IN BLUE OR BLACK INK
CHILD/YOUTH INFORMATION
Last Name First Name M.I.
Date of Birth D M Y Age Gender MALE FEMALE
Health Card Number (Required)
Medical Conditions or Allergies
Special Needs (i.e. ADD/ADHD, Autism, Learning Disabilities)Name of School Grade Name of Teacher
PARENT/GUARDIAN INFORMATION
Last Name First Name M.I.
Street Address Apartment/Unit #
City Province Postal Code
Home Phone ( ) E-mail Address
Cell Phone ( ) Other Phone ( )
EMERGENCY CONTACT
Last Name First Name M.I.
Home Phone ( ) Cell Phone ( ) Relationship to child/youth
Alternate Contact
Home Phone ( ) Cell Phone ( ) Relationship to child/youth
ACKNOWLEDGEMENTI hereby grant permission for my child to participate in all the activities of this program (which may include outings during program hours) and release Camp Promise and staff from any and all liability, claims, demands, personal injury, sickness, death, as well as property damage and expenses of any nature whatsoever, which may be incurred by the child participant. Further I grant permission to Camp Promise staff to authorize medical personnel to carry out any emergency procedure on my child in the case that I, or my emergency contact, cannot be reached at the time of the incident. In addition, I understand that photographs/video of my child taken during program may be used for promotional material. I have read and understood this waiver.
Parent/Guardian Signature Date
[email protected] 128 St. Vincent Street Barrie, ON L4M 3Y8 Tel: 705-726-9778 Fax: 705-722-5082
Registered with the Canada Revenue Agency Registration No. 128793049 RR 0001