Required fields are marked with asterisks (*)

Consent Form

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

Thank you for completing this vital form for camp.

Camper (first and last name)

Address

Child's hair colour

Child's eye colour

Child's shoe size

Child's age as of July 4

Does your child use a wheelchair

Does your child have a fear of animals?

Please rate your child's swimming ability

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

Indicate camp(s) your child is attending

Film Camp in a Box

Focus on Nature Photography

Fun Centre at RIM Park

Fun Centre at WMRC

Little Medical or Vet School or Wilderness Medicine

Stemotics

Summer Adventure

Variety (age 7-9)

Variety (age 10-12)

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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

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Parent/Guardian Names for Drop off and Pick up

Please indicate who has permission to drop off and pick up your child from camp. Note that government issued ID is required for entry into the facility.

If someone other than the names listed is to pick your child up from a site, our leaders will require the main contact's written consent.

How will your child arrive and depart from the program?

Walking, unsupervised

Biking, unsupervised

Dropped off/picked up by parent or guardian

List of names for drop off and pick up

Medical Information

If medication is to be administered during program time, a medical administration form must be completed on the first morning. This form may be obtained from the leaders at your program site. Note: camp staff cannot administer any medication other than oral medication and can assist with epi-pens if needed.

Allergies, food allergies or dietary restrictions

Medical conditions

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

Special needs

Please share information regarding your child's need or ability to assist our leaders in making your child's camp experience a great one.

Special notes

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If your child 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/leisuresupport 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 participant(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

Parent/Guardian Consent

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

Consent - participation

Yes

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Consent Form