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SUMMER CAMP REGISTRATION FORM Registrant’s Name: ____________________________________________

Male______

Female_____

Birth date: _____(day) _____(month) _____(year) Address: _________________________________________________________________________________________ City: _______________________ Province: __________________ Postal Code: ____________________________ Home Phone Number: __________________________ Parent/Guardian’s Name:_______________________ Alt. Phone Number: ____________________________ Parent/Guardian’s Name:_______________________ Alt. Phone Number: ____________________________ Email Address: ___________________________________________________________________________________ Family Medical #:__________________ (6 digits) Personal Medical #:__________________________(9 digits) EMERGENCY CONTACTS AND PICK-UP AUTHORIZATION

Does your child have any allergies, medical

The following people should be contacted in case

restrictions, or difficulties of any kind (i.e. hearing,

of emergency only if parent(s) or guardian cannot

speech, vision, behaviour) that we should be

be reached AND are authorized to pick up the

aware of: (please be specific)

child:

________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

1. Name: ____________________________________ Relationship to child:_________________________ Phone: Day (_____)____________________________ Evening (_____)________________________ 2. Name: ____________________________________ Relationship to child:_________________________ Phone: Day (_____)____________________________ Evening (_____)________________________ 3. Name: ____________________________________ Relationship to child:_________________________ Phone: Day (_____)____________________________ Evening (_____)________________________

Crescentwood 1170 Corydon Ave Phone: (204) 452-9844 Fax: (204) 284-2695

River Heights 1370 Grosvenor Ave Phone: (204) 488-7000 Fax: (204) 488-3224

www.centralcorydoncc.com

Sir John Franklin 1 Sir John Franklin Road Phone: (204) 489-9537 Fax: (204) 489-1720


CONSENT TO COLLECT, USE, AND DISCLOSURE OF PERSONAL INFORMATION I understand that, by completing this form the Central Corydon Community Centre is collecting certain personal information about my child, me and other members of my family (including, if necessary, my Manitoba Health Services Registration Number). I also understand that this personal information will be used only for the purpose of registering in the Community Centre’s Sport/Recreation/Youth Programs, and that such use will necessarily involve the disclosure of this personal information to the appropriate area sport association(s) and/or the appropriate sport umbrella group(s), Coach(es), Manager(s), Staff and the use of such disclosed personal information by such association(s), group(s), Coach(es), Manager(s) and Staff as may reasonably be required in order to conduct the Community Centre Sport/Recreational/Youth Programs. I hereby consent to such collection, use and disclosure of this personal information. Name of Registrant: __________________________________________________________________________________ Printed Name of Parent or Guardian of Registrant: ____________________________________________________ Signature of Parent or Guardian: __________________________________________ Date:

__________________

PARENT/GUARDIAN AUTHORIZATION I/We the parents/guardians of ______________ do hereby give my/our consent for him/her to participate in the program selected above. I/We understand that Central Corydon Community Centre, or its instructors will not be held responsible for any accident, injury or loss, however cause and to agree to release the aforesaid from all claims or damages which may arise as a result of, or by reason of, such accident, injury, loss or medical expense. 1. In the event that my child needs immediate medical attention for injuries received while participating in a C4 program, I authorize the staff to give my child reasonable first aid, and to arrange transport of my child to a health care facility for emergency services, and to release medical information to medical providers as needed. 2. My child has my permission to attend and participate in all C4 Summer Program Field Trips whether they are walking or being transported by bus. 3. I hereby acknowledge that the C4 will assume that either parent of the child may pick up the child at any time during the program unless there is pertinent court documentation on file at the C4 office that indicates otherwise. 4. I hereby release all pictures of my child taken by the C4 for promotional purposes and programming materials. 5. If my child requires use and administration of an epi-pen, it is my responsibility to ensure that the epi-pen is on my child or within their personal belongings every day of the program. If C4 staff are required to administer and use the epi-pen, I agree to forever release and discharge the C4 and it’s directors, officers, and employees from any and all liability arising out of or resulting from use or administration of the epi-pen. 6. I give my permission for the C4 Staff to administer sunscreen as needed. Name of Registrant: __________________________________________________________________________________ Printed Name of Parent or Guardian of Registrant: ____________________________________________________ Signature of Parent or Guardian: __________________________________________ Date:

Crescentwood 1170 Corydon Ave Phone: (204) 452-9844 Fax: (204) 284-2695

River Heights 1370 Grosvenor Ave Phone: (204) 488-7000 Fax: (204) 488-3224

www.centralcorydoncc.com

__________________ Sir John Franklin 1 Sir John Franklin Road Phone: (204) 489-9537 Fax: (204) 489-1720


SUMMER CAMP REGISTRATION FORM Which weeks of camp are you registering for: Sports Camp (6-12 years old)

Day Camp (6-12 years old)

July 3rd-6th: Ultimate Field Sport Week

July 3rd-6th: Around the World in 5 Days

July 9th-13th: Tennis

July 9th-13th: Who Dunnit'?

July 16th-20th: Flag Football

July 16th-20th: Game Show Mania

July 23rd-27th: Baseball

July 23rd-27th: Holiday Hoopla

July 30th-August 3rd: Floor Hockey

July 30th-August 3rd: Get Messy

August 7th-10th: Racquet Sports

August 7th-10th: Adventure Explorers

August 13th-20th: Outdoor Adventure

August 13th-20th: Greek Greatness

August 20th-24th: Dodgeball

August 20th-24th: Splish Splash Water Week

August 27th-31st: Sports Bonanza

August 27th-31st: Lets Make some Noise and Show some Spirit

Specialty Camp (6-12 years old)

Tot Camp (3-5 years old)

July 3rd-6th: Artful Antics

July 3rd-6th □Full Day □ ½ day am □½ day pm

July 9th-13th: Field Trip Camp

July 9th-13th: □Full Day □ ½ day am □½ day pm

July 16th-20th: Lights, Camera, Action

July 16th-20th: □Full Day □ ½ day am □½ day pm

Drama Camp

July 23rd-27th: □Full Day □ ½ day am □½ day pm

July 23rd-27th: Clowning Around

July 30th-August 3rd: □Full Day □ ½ day am □½ day pm

July 30th-August 3rd: Zumbatronic Party Camp

August 7th-10th: □Full Day □ ½ day am □½ day pm

August 7th-10th: No Bake Kids in the Kitchen

August 13th-20th: □Full Day □ ½ day am □½ day pm August 20th-24th: □Full Day □ ½ day am □½ day pm August 27th-31st: □Full Day □ ½ day am □½ day pm

Crescentwood 1170 Corydon Ave Phone: (204) 452-9844 Fax: (204) 284-2695

River Heights 1370 Grosvenor Ave Phone: (204) 488-7000 Fax: (204) 488-3224

www.centralcorydoncc.com

Sir John Franklin 1 Sir John Franklin Road Phone: (204) 489-9537 Fax: (204) 489-1720


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