Summer Camp Registration Page 1 of 5
Attach photo of child here
SUMMER CAMP
REGISTRATION 2014
General Information Sheet
Please note that Red Roof Retreat cannot provide 1:1 support for any child. Typically the ratio of staff to
children at Saturday Camp is 1:3. Red Roof Retreat has the right to accept or deny a registration at their
discretion or to send a child home early due to health, medical or behavioural concerns.
*If your child requires 1:1 support, they may attend camp with a worker - see p. 3
Child’s Name: ________________________________________________________________________________
Parent(s) Name(s): __________________________________________________________________________
Home Phone Number: ______________________________________________________________
Mom’s Work Phone Number: _______________________________________________________
Dad’s Work Phone Number: ________________________________________________________
Cell Number: _________________________________________________________________________
Email Address: _______________________________________________________________________________
Child’s Address: ______________________________________________________________________________
_____________________________________________________________________________
Child’s Diagnosis: ____________________________________________________________________________
Date Of Birth: __________________________________ Age: ______________________ Sex: ____________
Health Card Number: ________________________________________________________________________
Child’s Doctor: __________________________________________ Phone: ____________________________
Emergency Name & Contact Number (other than parents):
1. ____________________________________________________________________________________________
2. ____________________________________________________________________________________________
Person Responsible for dropping off child: _______________________________________________
Person Responsible for picking up child: _________________________________________________
Summer Camp Registration Page 2 of 5
Health Information Sheet
Brief Description of Disability/Diagnosis: ____________________________________________
________________________________________________________________________________________________
Allergies: yes ( ) no ( ) ____________________________________________________________________
Seizures: yes ( ) no ( ) ____________________________________________________________________
Shunt: yes ( ) no ( ) ________________________________________________________________________
Behavioural Concerns: yes ( ) please explain below
no ( )
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Medication:
( ) My child does not take any medication
( ) My child will not need medication during camp hours
( ) My child will need medication at camp
*Please list medications below. All medications need to be listed, even if your child does not require
medication during camp hours.
Medication
Dosage/Time
Route
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Mobility:
( ) Walks independently
( ) Uses manual chair
( ) Uses electric chair
( ) Uses walker/crutches
Toileting/Dressing/Hygiene:
( ) Independent
( ) Some assistance required
( ) Total assistance required
Feeding/Nutrition:
( ) Eats Independently
( ) Needs some assistance
( ) Hand-over-hand required
( ) Needs total assistance
( ) Tube Fed
Communication:
( ) Verbal/Speaking
( ) Non-Verbal/Non-Speaking
( ) Uses Augmentative
Communication
( ) Sign Language
Summer Camp Registration Page 3 of 5
Summer Camp 2014:
( ) Jr. Camp (5 - 15 years)
( ) Sr. Camp (16 - 21 years)
Both Camps run from 9:00am to 3:00pm (late charges of $15 for every quarter hour)
Please check dates child will be attending below:
(
(
(
(
(
(
) July 7 - 11
) July 14 - 18
) July 21 - 25
) July 28 - August 1
) August 4 - 8
) August 11 - 15
To Register, you must complete all of the following:
1.
2.
3.
4.
Application Form
Signed Waivers (see attached)
Attach Photo of Child
Payment
Confirmation and receipts will be issued when above requirements are complete
We are unable to issue refunds without adequate notice or a doctor’s note if
applicable. However, IF we are able to fill the spot, we will reimburse you.
To Register:
Registration and payment can be sent to:
Red Roof Retreat
1594 Concession Six, RR #2
Niagara On The Lake, ON L0S 1J0
Full Summer Camp Week
$225.00 x number of weeks =
Full Summer Camp Week *with worker
$110.00 x number of weeks =
$________________________
$________________________
*IF your child requires 1:1 support, they may attend camp with a worker. Please fill
in the name of your worker: ________________________________________________________________
Method of payment: ( ) Cash
( ) Cheque
( ) Credit Card complete below
( ) Visa ( ) Master Card #: _________________________________________ Expiry Date: _________________
I/we the parent(s)/guardian(s) are aware of this application and are in agreement with the
above application requirements (ie. payment of fees and waivers to be signed). I/we are
aware of the nature of Red Roof Retreat’s programs and give consent for my/our child to
participate.
Name(s) please print: ___________________________________________________________________________________
Signature(s): _________________________________________________ Date: __________________________________
Summer Camp Registration Page 4 of 5
Photo/Video Release
I, ______________________________________, consent to the use of any photos or videos taken of my
child during Summer Camp.
Name(s) please print: ___________________________________________________________________________________
Signature(s): _________________________________________________ Date: __________________________________
Oath of Confidentiality
To demonstrate respectfulness to others, I/we agree to keep confidential all information
concerning other children/families being served by the Red Roof Retreat/Niagara Children’s
Centre Summer Camp program.
Name(s) please print: ___________________________________________________________________________________
Signature(s): _________________________________________________ Date: __________________________________
Release and Indemnification
In consideration of Red Roof Retreat/Niagara Children’s Centre accepting within the
application, I, _________________________________, parent/guardian of _________________________________,
agree to indemnify and hold harmless Red Roof Retreat and the Niagara Children’s Centre,
its servants, agents or employees and all other organizers, sponsors, representatives and any
other person or organization assisting in this Summer Camp program from any claims,
demands, damages, actions or causes of actions arising out of or in consequence of any loss,
injury or damage to my person or my property incurred while attending at or participating
in the Summer Camp, notwithstanding any such loss, injury or damage that may have risen
by reason of the negligence of Red Roof Retreat and the Niagara Children’s Centre, its
servants, agents or employees and all other organizers, sponsors, representatives and any
other person or organization assisting in this Summer Camp program, arising out of or in
consequence of the attendance or participation by
_________________________________________________ at the Summer Camp operated by Red Roof
Retreat and the Niagara Children’s Centre.
Name(s) please print: ___________________________________________________________________________________
Signature(s): _________________________________________________ Date: __________________________________
Summer Camp Registration Page 5 of 5
Thank you for registering for
Red Roof Retreat’s
Summer Camp 2014
Please print and keep this sheet for helpful tips & information when preparing to send your child to camp.
Drop Off & Pick Up
 Summer Camp starts at 9:00am and ends at 3:00pm each day
 Drop off and pick up will always be at the Niagara Children’s Centre located at 567
Glenridge Avenue in St. Catharines. Use the red sliding doors on the North side of the
building.
 An adult (name must be listed on the registration form) must sign the child/teen in
and out every day
 *Late fees of $15/15 minutes will be applied for any late pick ups
 If your child will be absent for a day of camp or if there is a change in plans
regarding who will pick your child up, please call the camp Supervisor (name and
number will be provided to you on the first day of camp).


JR CAMP - Campers will be bussed to the Red Roof Retreat site located in Niagara
On The Lake on Tuesdays & Thursdays for a day of outdoor activities (weather
permitting). In case of inclement weather, Fridays may be used as an alternate day.
SR CAMP - Campers will be bussed to the Red Roof Retreat site located in Niagara
On The Lake on Mondays & Wednesdays for a day of outdoor activities (weather
permitting). In case of inclement weather, Fridays may be used as an alternate day.
Daily Supplies
Each day, your child should bring the following labeled items to camp in a labeled bag:
 Lunch and drinks packed with an ice pack
 Water bottle
 Change of clothes
 Bathing suit & towel
 Reusable swimmers for campers who are incontinent
 Hat
 Sunscreen
 Bug spray
*You will be responsible for checking that you have all of your child’s belongings at the end
of the day. We are not responsible for lost items.
** For campers who require a feeding tube or medication, please write out clear
instructions along with daily supplies and pack in Ziploc bag or container labeled with
child’s name. Please note that ALL medications MUST be in an original pill bottle
with an up to date, readable label from the pharmacy.
At the beginning of each day, please apply sun screen and bug repellent to your child
before they arrive at camp. Our staff/volunteers will reapply these after swims and/or
before going outside.
Thank you for your cooperation!