CHILD’S INFORMATION
FIRST
LAST
NAME
NAME
BIRTH DATE
DD
/
MM
/
YYYY
GENDER
F
M
ADDRESS
TOWN
POSTAL CODE
# HEALTH
EXPIRATION
INSURANCE
/
MM
YY
HEALTH INFORMATION
ALLERGIES
PENICILLIN
BEES
EGGS
SEASONAL ALLERGIES
NO ALLERGY
PEANUTS AND NUTS
OTHER
:
DOES YOUR CHILD HAVE AN AUTOINJECTOR (EPIPEN) OR DOES HE/SHE TAKE DRUGS
RELATED TO ALLERGIES DURING CAMP HOURS?
YES
NO
YES
NO
DOES HE/SHE NEED TO TAKE DRUGS?
YES
NO
IF YES, DOES IT HAVE TO BE ADMINISTERED DURING CAMP HOURS?
YES
NO
YES
NO
IF SO, WHICH
MEDICAL PROBLEMS
DOES YOUR CHILD HAVE SOME PROBLEMS REQUIRING SPECIAL ATTENTION
(DISABILITY, DISEASE, HYPERACTIVITY, FEAR, ETC.)?
IF SO, WHICH
MEDICATION
DOSAGE
POSSIBLE SIDE EFFECTS
SWIMMING
DOES YOUR CHILD NEED TO WEAR A PFD (FLOTATION DEVICE)?
IF YES, WE WILL SUPPLY YOUR CHILD WITH A PFD DURING THE ACTIVITIES AT THE SWIMMING
POOL. ACTIVITIES AT THE SWIMMING POOL WILL ALWAYS BE SUPERVISED BY A QUALIFIED
LIFEGUARD.
I AUTHORIZE THE MANAGEMENT OF SUTTON’S DAY CAMP TO MAKE DECISIONS THAT WILL BE REQUIRED TO ENSURE THE HEALTH AND THE
SAFETY OF MY CHILD. I ALSO AUTHORIZE THE DAY CAMP’S STAFF TO GIVE EMERGENCY FIRST AID AND CALL THE AMBULANCE IF NEEDED. (NO
COUNTER MEDICATION OR PRESCRIPTION MEDICATION WILL BE ADMINISTERED WITHOUT THE WRITTEN CONSENT OF THE PARENT)
SIGNATURE :
DATE :
PARENT’S INFORMATIONS
CHECK WHO WILL RECEIVE THE TAX RECEIPT
FATHER
MOTHER
SOCIAL INSURANCE NUMBER :
SOCIAL INSURANCE NUMBER :
MOTHER’S NAME
FATHER’S NAME
ADDRESS
ADDRESS
HOME
WORK
CELL PHONE
(
)
-
(
)
-
(
)
-
HOME
WORK
CELL PHONE
(
)
-
(
)
-
(
)
-
IN THE CASE OF EMERGENCY (OTHER THAN PARENTS)
EMERGENCY CONTACT NAME
(
)
-
RELATIONSHIP TO THE CHILD
AUTHORIZATION
PHOTOGRAPHY
I AUTHORIZE SUTTON’S DAY CAMP TO USE PICTURES TAKEN DURING ACTIVITIES IN WHICH WE SEE MY CHILD, AND THIS FREE
AND WITHOUT DISCOUNT. THESE PICTURES WILL BE USED ONLY FOR THE PROMOTION OF THE DAY CAMP’S ACTIVITIES.
YES
NO
INITIAL :
DEPARTURE FROM DAY CAMP
I AUTHORIZE MY CHILD TO LEAVE THE DAY CAMP ALONE
INITIAL :
MY CHILD CANNOT LEAVE THE DAY CAMP ON HIS/HER OWN. THE AUTHORIZED PERSONS ALLOWED TO PICK HIM/HER UP IS :
REFUND POLICY
IN CASE OF CANCELLATION BY THE PARTICIPANT MORE THAN A WEEK BEFORE THE START OF THE ACTIVITY, A FULL REFUND WILL BE
MADE. HOWEVER, THE TOWN WILL RETAIN AN ADMINISTRATION FEE OF FIFTEEN PERCENT (15%).
IN CASE OF CANCELLATION BY THE PARTICIPANT LESS THAN A WEEK BEFORE THE START OF THE ACTIVITY, A REFUND OF FIFTY PERCENT
(50%) OF THE REGISTRATION COST WILL BE MADE.
NO REFUNDS WILL BE MADE AFTER THE START OF THE ACTIVITY, EXCEPT FOR MEDICAL REASONS WITH WRITTEN PROOF FROM A
DOCTOR.
Registration
Check your choices
Week 1
(June 22, 23, 25 and 26,
2015)
Week 2
(June 30 and 31 and July 2
and 3, 2015)
Week 3
(July 6 to July 10, 2015)
Week 4
(July 13 to July 17, 2015)
Week 5
(July 20 to July 24, 2015)
Week 6
(July 27 to July 31, 2015)
Week 7
(August 3 to August 7, 2015)
Week 8
(August 10 to August 14,
2015)
Day camp
(9 :00 am to 4 :00 pm)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Morning day care
(7 :30 am to 9 :00 am)
52 Residents
76 Abercorn
96 Non-residents
52 Residents
76 Abercorn
96 Non-residents
65 Residents
95 Abercorn
120 Non-residents
65 Residents
95 Abercorn
120 Non-residents
65 Residents
95 Abercorn
120 Non-residents
65 Residents
95 Abercorn
120 Non-residents
65 Residents
95 Abercorn
120 Non-residents
65 Residents
95 Abercorn
120 Non-residents
Afternoon day care
(4 :00 pm to 5 :00 pm)
$ 17
$11
$ 17
$ 11
$ 21
$ 14
$ 21
$ 14
$ 21
$ 14
$ 21
$ 14
$ 21
$ 14
$ 21
$ 14
Cost
Reserved to the
administration
Total amount to be paid
Resident’s rates for weeks 1 and 2: 1st child enrolled $ 52 / 2nd child enrolled $ 48 / 3rd child enrolled $ 46
Resident’s rates for weeks 3 to 8: 1st child enrolled $ 65 / 2nd child enrolled $ 60 / 3rd child enrolled $ 57
* The family discount does not apply to residents of Abercorn and non-residents.
LATE REGISTRATION FEE
A fee of fifteen dollars ($ 15.00) will be payable for all registrations made after May 29, 2015.
PAIEMENT METHOD
CHEQUE :
CASH :
There is the possibility of making two cheques in the same amount, dated June 2, 2015 and July 2, 2015. You have
to bring your registration form and the payment to the Town Hall before May 15, 2015, to complete your
registration. Cheques should be made payable to the Town of Sutton.
CONDITIONS OF NON LIABILITY AT THE DAY CAMP
SUTTON DAY CAMP DISCLAIMS ALL LIABILITY FOR ANY INJURY INCURRED BY THE CHILD AND ANY DAMAGE TO THE PROPERTY OR ITEMS LOST DURING DAY CAMP
ACTIVITIES.
I,
(PARENT/GUARDIAN)
ACTIVITY, EVEN IF EVERY PRECAUTION
,
PARENT/GUARDIAN OF
I AGREE TO NOTIFY SUTTON’S DAY CAMP IN
I WILL ASSUME THE COSTS FOR CHILD CARE SERVICES,
OTHER THAN THAT OF THE SUMMER DAY CAMP KNOWING THAT THIS SERVICE WILL NOT BE AVAILABLE DURING THE ACTIVITY (EG. : TRIP).
IS TAKEN BY
SUTTON’S
ACCEPT THAT RISKS CAN OCCUR DURING THE
(CHILD’S NAME)
DAY CAMP TO ENSURE THE SAFETY OF MY CHILD.
WRITING IF MY CHILD CANNOT PARTICIPATE IN CERTAIN ACTIVITIES OF THE DAY CAMP. IN THESE CASES,
I HAVE READ THIS CLAUSE AND WAIVE ALL CLAIMS OF ANY KIND
CAMP FOR DAMAGES RELATING TO THE REGISTERED ACTIVITY.
AGAINST
SUTTON’S DAY CAMP,
ITS INSURERS AND ANY PERSON EMPLOYED BY
I HAVE READ THE REGISTRATION DETAILS AND REFUND POLICY AND AGREE TO ABIDE BY THEM.
SIGNATURE : __________________________________
Date :
DD
/
MM
/
YYYY
SUTTON’S DAY