Required fields are marked with asterisks (*)

March Break camp consent form

All forms must be completed a week prior to the first day of camp. Thank you!

Camper information

Camper (first and last name)

Address

Camper hair colour

Camper eye colour

Camper shoe size

Camper age as of March 10

Friend/cohort request (up to 2 names, campers within two years of age)

Add another child Remove

Main Parent/Guardian Contact Information

Please list your phone numbers and contact information so we may contact you in the event of an emergency.

Main parent/guardian name

Preferred name (if applicable)

Parent/guardian home telephone number

Parent/guardian work or cell phone number

Parent/guardian email address

Emergency Contact Information

In a case where we cannot reach the main contact, we will try to reach the alternate contact.

Emergency contact name

Emergency contact telephone number

Emergency contact email address

Second emergency contact name

Second emergency contact telephone number

Second emergency contact email address

Add Remove

Parent/Guardian Names for Drop off and Pick up

Please indicate who has permission to drop off and pick up your camper from camp. Government issued ID is required.

If someone other than the names listed is to pick your camper up from a site, our leaders will require the main contact's written consent
Campers must be 10 years of age or older in order to arrive or depart the program unsupervised.

How will your camper arrive and depart from the program?

Walking, unsupervised

Biking, unsupervised

Dropped off/picked up by parent or guardian

Provide a list of names for drop off and pick up

Medical Information

If medication is to be administered during program time, you must complete a medical administration form.

Camp staff can only help administer oral medications and assist with epi-pens. They can't administer any other medications.

Allergies, food allergies or dietary restrictions

Medical conditions

Does your camper have an Educational Assistant (EA) that helps them at school?

Yes

Special needs

List language(s) your camper speaks and understands

Is there anything you’d like your camper’s leaders to know in advance about your child?

Your camper's interests

List 4 words that best describes your camper

Add another child Remove this child

Support

If your camper has a disability or special need and requires accommodation to participate in our programs, one-to-one assistance may be available. Accommodation fills quickly - please register early to ensure support is available. Learn more at www.kitchener.ca/inclusion-support or call 519-741-2229.

Emergency Medical Treatment

In the event of an accident or illness involving my child while attending the program I hereby authorize, if I am not immediately available, the administration of any medical procedure deemed necessary by the child's physician, or any other physician selected by the program staff. I also give my permission for my child to be transported to the physician's office or the hospital Emergency Department with no liability on the drivers's part. An ambulance may be called to transport my child to the hospital if required; billing for the ambulance will be forwarded to the main contact specified on the registration form.

Consent - medical

Yes

Excursions off the Property

The child(ren) listed above may be taken away from the program premises by the staff, by means of any manner of public or private transportation or otherwise, for walks, picnics or outings of any kind and may, from time to time, be scheduled as part of the program.

Routine activities for all camps may include walking to and from the park, walking on trails and around the facility as well as using the green space in and around the facility.

Please note that you will be required to sign an informed consent form listing details if there are more excursions off the property than what are listed. Staff do not drive participants for any reason.

Consent - excursions

Yes

Authorization for publicity

The above mentioned camper(s) may appear in advertising/publicity arranged by the City of Waterloo through various media outlets including newspaper, radio, tv, slide presentations and printed or electronic publications.

Consent - publicity

Yes

Consent for snacks and treats

Some leaders may choose to give out food during the week. This may include treats such as hot chocolate and marshmallows or pre-packaged snacks such as granola bars, apple sauce, fruit snacks, bear paws, etc. Allergens declared on this consent form will not be served to your camper. A listing of special treat days will be noted on the camp flyer.

Consent - snacks and treats

Yes, I allow camp staff to feed my child foods listed above.

No, I do not allow camp staff to feed my child any food.

Parent/Guardian Consent

Make sure to read our information package (PDF) - it has everything you need to know about attending camp this March Break.

As the campers parent or guardian, I have read and understood the specific program details outlined above and give permission for participation.

Yes

As the campers parent or guardian, I have read and understood I’ve read and understood the March Break camp information package.

Yes

Parent/Guardian signature

Clear

Under the authority of the Municipality Act, 2001, S.O., Personal Information, including Personal Health Information, will be collected for the administration of the camp program. As part of the camp program, participants' health information collected will to ensure safe and supportive programming for each participant. If you have any questions regarding the collection and handling of this personal information, please contact Community Leisure Programming at camp@waterloo.ca, 519-886-1177 x 27280 or 100 Regina Street South, Waterloo, Ontario, N2J 4A8.

Form Builder