1594 Concession Six, R.R. #2
Niagara-on-the-Lake, ON L0S 1J0
www.redroofretreat.com
Ph: 905-684-0235
Fax: 905-684-5477
Summer Camp Registration 2013
Registration is complete only when these forms, waivers and fees are received.
General Information Sheet
Child’s Name____________________________________________________________
Parents’ Name/s__________________________________________________________
Home Phone: ________________________________
Mom’s Work Phone: __________________________
Dad’s Work Phone: ___________________________
Cell Number: ________________________________
E-Mail Address: ____________________________________________
Child’s Diagnosis: ________________________________________________________
Date of Birth: ______________________Age:______________________Sex:_________
Health Card #:____________________________________________________________
Child’s Doctor: _________________________________Phone:____________________
Child’s Address: ______________________________
___________________________________________
___________________________________________
___________________________________________
If sibling/s attending:
Name
_____________________
_____________________
Age
____________
____________
Health Card Number
___________________________
___________________________
Emergency Name and Contact Number:
1) _____________________________________________________________________
2) _____________________________________________________________________
Person responsible for dropping off child: ______________________________________
Person responsible for picking up child: _______________________________________
Page 2
Health Information Sheet
Brief Description of Disability/Diagnosis: ____________________________________
________________________________________________________________________
Allergies: yes ( ) no ( ) ________________________________________
Seizures: yes ( ) no ( ) _________________________________________
Shunt: yes ( ) no ( ) ___________________________________________
Behavioral Concerns: yes( ) please explain
no( )
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________
Medication: yes ( ) no ( )
If medication needs to be administered at camp, please fill out the following:
Medication
Dosage/Time
Administration
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________________
Mobility:
Walk independently ( )
Uses a manual chair ( )
Uses electric Chair ( )
Uses walker or crutches ( )
Toileting/Dressing/Hygiene:
Independent ( )
Some assistance required ( )
Total assistance required ( )
Feeding/Nutrition: (*Lunches and Feeding Instructions to be provided by family)
Eats independently ( )
Needs some assistance ( )
Hand-over-hand ( )
Needs total assistance ( )
Tube fed ( )
Communication:
Verbal/ Speaking ( )
Non-Verbal/Non-Speaking ( )
Uses Augmentative Communication ( ) or Sign Language ( )
Page 3
Registration
Summer Camp Weeks for Junior and Senior
are:
Junior Camp (5 to 15 years old):
Senior Camp (16 – 21 years old):
**New Hours-Full day - 9:00 am to 3:00pm**
July 8-12 __________
July 15-19 __________
July 22-26 _________
July 29-Aug 2________
August 5-9 ________
August 12-16________
Registration is complete only when these forms, waivers and fees are received.
Confirmation/Receipts will be issued upon receipt of the above requirements.
Sorry, we are unable to give refunds without adequate notice
or a doctor’s note if applicable.
However, IF we have notice and can fill the spot, we will reimburse you.
Send payment and registration to:
Red Roof Retreat
1594 Concession Six, R.R. #2
Niagara on the Lake, ON L0S 1S0
Fees for full-day program is $220.00 x # of weeks ________ = $_____________________
Amount paid: $_________ Method of payment: Cash _____ Cheque _____ Credit Card ______
Visa ___ MC ____ # ___________________________________ Expiry Date _________
* If you would like to send a SSAH Worker with your child, the fee will be reduced to $110.00 per week.
Please fill in the name of your worker: ________________________________________
Amount paid is $110.00 x # of weeks______ = $________________________________
Amount paid: $_________ Method of payment: Cash _____ Cheque _____ Credit Card ______
Visa ___ MC ____ # ___________________________________ Expiry Date _________
An updated photo must be attached to the registration form
I/we the parent(s)/guardian(s) are aware of this application and are in agreement with the above
application requirements (i.e. payment of fees and waivers to be signed).
I/we are aware of the nature of the RRR Summer camp programs and give consent for my child to
participate.
Signature(s) ____________________________________________________________
PHOTO/VIDEO RELEASE
I, _____________________________ consent to the use of any photos or videos taken of my
child/children during summer camp.
Dated: _____________
Signature of Parent/Guardian: ________________________
OATH OF CONFIDENTIALITY
To demonstrate respectfulness to other I/We agree to keep confidential all information concerning other
children/families being served by the “Niagara Peninsula Children’s Centre/Red Roof Retreat Summer
Camp” program.
Signature of Parent/Guardian: _________________________
Date: _______________
RELEASE AND INDEMNIFICATION
In consideration of Red Roof Retreat/Niagara Peninsula Children’s Centre accepting the within application,
I, ____________________________ parent/guardian of __________________________ agree to
Indemnify and hold harmless the Niagara Peninsula Children’s Centre and Red Roof Retreat, its servants,
agents or employees and all other organizers, sponsors, representatives, and any other person or
organization assisting in this camp from any claims, demands, damages, actions or causes of actions arising
out of or in consequences of any loss, injury or damage to my person or property incurred while attending
at or participating at the summer camp, notwithstanding any such loss, injury or damage may have risen by
reason of the negligence of the Niagara Peninsula Children’s Centre and Red Roof Retreat, its servants,
agents, or employees and all other organizers, sponsors, representatives and any other person or
organization assisting in this camp, arising out of or in consequence of the attendance or participation by
__________________________ at the summer camp operated by the Niagara Peninsula Children’s
Centre and Red Roof Retreat.
Parent/Guardian Signature_____________________________________
Date____________________
Thank You for Registering for
Red Roof Retreat
Summer Camp
2013
Here is some information you may find useful in order to make arrangements.
Drop Off and Pick Up
PLEASE BE PROMPT
Camp starts at 9:00am and ends at 3:00pm each day.
Pick up and drop off will always be at the Niagara Peninsula Children’s Centre
(Located on Glenridge Ave: use red doors at the left-hand side of the building)
*Late fees will be applied*
If your child will be absent, or if there is a change in plans regarding who will pick up your child, please call
your child’s camp supervisor (name and number will be provided first day of camp)
Tuesdays and Thursdays – Each Tuesday and Thursday, Junior Campers will be bused to Red Roof Retreat
for a day of outdoor activities (weather permitting), Youth Campers will go on Monday, Wednesdays and
Fridays.
Daily Supplies – Each day your child must bring the following things to camp in a labeled bag or knapsack:
-Lunch and drinks packed with an ice pack
-Water bottle
-Change of clothes
-Hat
-Sunscreen
-Bug Spray
-Swimsuit and Towel
*For campers who require tube feeding or medication, please write out clear instructions along with daily
supplies (please put in Ziploc bag or container with child’s name). We will take them out of their knapsacks
each day and put in safe storage.
*Please check that you have all your child`s belongings at the end of each day. We are not responsible for
lost items.
Please adhere to the following procedure each day your child is to come to Red Roof Retreat Summer
Camp.
-Apply bug repellant and sunscreen
-Label your products and put them in your child’s knapsack each day.
Our staff/volunteers will reapply these after swims and before going outside.