Aspiral Licenced Childcare
Phone: (250) 832-0108 SALMON ARM
Phone: (250) 803-2013 CANOE
Email: childcare@youthpartners.ca
Summer Day Camp Form – Ages 21/2 – 5
Pirates
July 2-5
Space
& Superheroes
July 29- August 2
Oceans
July 8-12
Castles
& Fairy Tales
Reptiles
July 15-19
Chefs Creating
August 20-24
Dinosaurs
July 22-26
At the Circus
August 19-23
August 6-9
Name of Child: ___________________________________________________________
First
Last
Sex:
Male
Female
Age: ___________ Birth Date: __________________
Month/Day/Year
Parent/Guardian Name: ____________________________________________________
First
Last
Home Phone: _________________
Work Phone: ________________________
Other Phone: _________________ Relationship to Child: _________________________
Parent/Guardian Name: ____________________________________________________
First
Last
Home Phone: _________________
Work Phone: ________________________
Other Phone: _________________ Relationship to Child: _________________________
Person the Child lives with: _________________________________________________
Address: ________________________________________________________________
Street
City
Postal Code
Email: __________________________________________________________________
* Email will be used for purposes of Childcare and/or Preschool business only
Photo Permission:
I give permission for my child ______________________________, to be photographed
___ (initial) or videotaped___ (initial) during an Aspiral Licenced Childcare event. I
understand that these pictures may be used in displays onsite ___ (initial) websites___
(initial) and/or published ___ (initial).
I give permission for my child _____________________________, to use sunscreen y/n,
to use insect repellant y/n, to use after bite y/n.
__________________________________
Signature of Parent/Guardian
____________________________________
Print Name of Parent/Guardian
__________________________________
Date
Spontaneous Field Trips Permission:
I give permission for my child ______________________________, to participate in
spontaneous walks or city bus trips with the Aspiral Licenced Childcare staff.
__________________________________
Signature of Parent/Guardian
____________________________________
Print Name of Parent/Guardian
__________________________________
Date
Immunization Declaration:
My child __________________________ is up to date with all immunizations as of
today’s date, _______________________.
OR
My child __________________________ is NOT up to date with all immunizations as of
toady’s date, _______________________.
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What to Bring to Summer Day Camps:
 Sunscreen
 Weather appropriate clothing for adventuring (hats, jacket, sunglasses, etc)
 Water bottle
Location:
 451 Shuswap St SW Salmon Arm, SASCU DAC
 9:00am – 11:30am
Cost:
 $50/week per child
 Registration fee is $50 per family, fee waived if you register before June 15th
LICENSED CHILCARE
SUMMER FUN DAY CAMPS
Pirates
July 2-5 (4day week)
Oceans
July 8-12
Reptiles
July 15-19
Dinosaurs
July 22-26
Space &
Superheroes
July 29- August 2
Castles &
Fairy Tales August 6-9 (4day wk)
Chefs Creating
August 12-16
At the Circus
August 19-23
Registration Fee (new families
only) $50
TOTAL OWING
TOTAL PAID
*Copy this page for parent
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$50 ea
or $40 for
4day weeks
EMERGENCY PERMISSION CARD
Aspiral Licenced Childcare
Date: _______________________________
Child’s Name: ________________________
Child’s Photo
We are happy to take
a photo of your child
Hair Colour: _________________________
Eye Colour: __________________________
Birth date: ___________________________
Address: ____________________________
Home Phone: ________________________
Mother’s Name: _____________________ Father’s Name: _______________________
Work Phone: ________________________ Work Phone: _________________________
Home Phone: ________________________ Home Phone: ________________________
Cell Phone: __________________________ Cell Phone: __________________________
Emergency Contact: __________________ Phone: _____________________________
Cell Phone: __________________________ Work Phone: _________________________
Child’s Doctor: ______________________ Phone: _____________________________
Child’s Care Card #:__________________________________________
Date of last Tetanus shot: ______________ Allergies: ____________________________
Medical Conditions: ___________________ Medication(s): _______________________
Child’s Dentist: _______________________ Phone______________________________
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Emergency Consent:
If I cannot be reached by phone and there is an illness or accident involving my child
____________________________, I authorize Aspiral Licenced Childcare to send for or
seek medical assistance. I agree that the day care provider/s, in an emergency, may call
an ambulance. I give consent for my child to receive medical treatment in an emergency.
I understand I am responsible for all costs incurred.
____________________________
Signature of Parent/Guardian
___________________________
Print Name of Parent/Guardian
If I cannot be reached by phone and there is an illness or accident involving my child
____________________________, I authorize the above named Emergency Contact to
pick up my child.
__________________________________
Signature of Parent/Guardian
____________________________________
Print Name of Parent/Guardian
____________________________
Date
Allergies/Reactions/Treatments:______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Medical Issues/Symptoms/Treatments: ________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Authorization to pick up a child:
The following people are authorized to pick up my child; other than the parent/s and or
guardian/s (please include emergency contact):
Name
Relationship to Child
Is there a custody or agreement or issues?
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Phone Number
Yes
No