1081 Cadboro Rd., Ottawa, ON, K13 7T8
Phone: 613-741-8000 www.orthodoxy.ca
Participant(s) Information
1. Name: _____________________________Boy___ Girl___ Birth Date (D-M-Y) _______________Grade in Fall 2014_______
2. Name: _____________________________Boy___ Girl___ Birth Date (D-M-Y) _______________Grade in Fall 2014_______
3. Name: _____________________________Boy___ Girl___ Birth Date (D-M-Y) _______________Grade in Fall 2014_______
Street Address: _______________________________City: ___________Province: _______________Postal Code: ___________
Home Phone: ________________________________ Language(s) spoken at home: ____________________________________
Parent Information
Mother: Father:
Name: ___________________________________________ Name: _______________________________________________
Home Address: ____________________________________ Home Address: _______________________________________
(If different than above) (If different than above)
Employer: ________________________________________ Employer: ____________________________________________
Work Address: ____________________________________ Work Address: ________________________________________
Work Ph.: ________________________________________ Work Ph.: ____________________________________________
Cell Ph.: _________________________________________ Cell Ph.: _____________________________________________
Email: __________________________________________ Email: _______________________________________________
Emergency Contacts
1. Name: _______________________________________ 2. Name: ____________________________________________
Relationship: ____________________________________ Relationship: __________________________________________
Main Ph.: _______________________________________ Main Ph.: _____________________________________________

Authorized Drop-off and Pick-Up
1. Name: _______________________________________ 2. Name: ____________________________________________
Relationship: ____________________________________ Relationship: _________________________________________
Main Ph.: _______________________________________ Main Ph.: ___________________________________________
Medical Information
Physician's Name: ________________________________ Address: __________________________Phone:______________
Health Card No.: 1. _______________________________ Expiry: __________________________ Epipen? Yes ___No___
Health Card No.: 2. _______________________________ Expiry: __________________________ Epipen? Yes ___No___
Health Card No.: 3. _______________________________ Expiry: __________________________ Epipen? Yes___ No___
Allergies (Please describe and specify severity):
1. _____________________________________________________________________________________________________
2. ____________________________________________________________________________________________________
3. ____________________________________________________________________________________________________
Dietary Restrictions:
1. _____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
Ongoing Medical Concerns:
1. ____________________________________________________________________________________________________
2. _____________________________________________________________________________________________________
3. _____________________________________________________________________________________________________
I/We give permission that in the event of illness or an accident occurring to my child/children , Summer Program staff will make every attempt to contact me and/or other parent. If I or other parent cannot be reached, I/we hereby give Summer Program staff the authority to act on my/our behalf in case of an emergency and to take appropriate steps to seek medical attention/have a doctor attend to my/our child/children. Yes ___ No ___
Photo Consent and Authorization
Throughout the summer we capture memories of Summer Program through photographs. These photos when displayed help communicate the varied activities throughout the summer. This consent only covers internal program use. Separate permission forms are required for photos to be used for promotional purposes.
___ I consent to the use of my child's photo for internal use at Summer Program.
___ I do not consent to the use of my child's photo for internal use at Summer Program .

Field Trip Consent and Authorization
Throughout the summer weekly field trips will be scheduled to enrich the Summer Program experience for your child/children.
This consent covers weekly field trip participation.
___ I consent to my child's/children's participation in field trips .
___ I do not consent to child's/children's participation in field trips .
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NOTES

Registration fee of $250 per child, for the entire summer, is due with registration.

Early Bird discount of $25 per child is applied for full payment made by Sunday June 7th, 2015

The Summer Program fee includes the cost of the weekly field trip.

Days absent from camp are not subject to a refund of a portion of the fee.

Participants provide their own lunch and snacks daily.

Extended care service is available from 7:00am-8:00am and/or from 4:00pm-5:30pm at $15.00 per day/child.

Please make cheque payable to: St. George and St Anthony Coptic Orthodox Church of Ottawa.

For children safely, parents should not be sending to the camp a kid suffering from fever, vomiting, diarrhea or any suspicious symptoms (rash, spots…etc.)
Please Circle Weeks /Days Your Child/ Children Plan to Attend the Summer Program
Weeks (Please Circle) Days (Please Circle) Extended Care (Please Circle)
1 July 02 - 03 (2 days)
2 July 06 - 10
TH02 F03
M06 T07 W08 TH09 F10
TH02 F03
M06 T07 W08 TH09 F10
3 July 13 - 17
4 July 20 - 24
5 July 27 - 31
6 Aug. 04 - 07 (4 days)
M13 T14 W15 TH16 F17
M20 T21 W22 TH23 F24
M27 T28 W29 TH30 F31
T04 W05 TH06 F07
M13 T14 W15 TH16 F17
M20 T21 W22 TH23 F24
M27 T28 W29 TH30 F31
T04 W05 TH06 F07
7 Aug. 10 - 14
8 Aug. 17- 21
M10 T11 W12 TH13 F14
M17 T18 W19 TH20 F21
M10 T11 W12 TH13 F14
M17 T18 W19 TH20 F21
Cancellation Policy
Parent's may cancel a Summer Program registration before June 21, 2015 and obtain a refund. After that date there is no refund.
I/ We hereby apply for admission of the above mentioned child/children. I/We have read and understand the registration information and agree to be bound by its content.
Signature of Parent: ______________________________
Signature of Parent: ______________________________
Date: _____________________________________
Date: _____________________________________