Summer Camp Registration

Child’s Information

Child’s Name(required)

Child’s D.O.B.(required)

Child’s Gender(required)

Child’s Eye Color(required)

Child’s Hair Color(required)

Child’s Height(required)

Child’s Weight(required)

Parent / Guardian Information (1)

Name(required)

Relationship to Child(required)

Phone(required)

Work Phone(required)

Email(required)

Address(required)

Workplace(required)

Parent / Guardian Information (2)

Name(required)

Relationship to Child(required)

Phone(required)

Work Phone(required)

Email(required)

Address(required)

Workplace(required)

Emergency Contact Information

Name(required)

Relationship to Child(required)

Phone(required)

Work Phone(required)

Do you authorize this person to pick up your child?(required) Yes

Are there any specific individuals who are not allowed access to your child?(required) Yes

If you answered yes to the previous question please provide name/s

Medical Information

Dr’s Name(required)

Dr’s Phone(required)

BC Care Number(required)

My child is up to date with immunizations (please email copy of immunization record to fernieschoolagedcare@gmail.com)(required) Yes

If you answered no to the previous question please provide details (e.g. chose not to vaccinate)

Does your child suffer from any allergies (including environmental and food sensitivities)?(required) Yes

If yes, please provide details (e.g. dairy non life-threatening, all nuts anaphylactic and has EpiPen)

Does your child suffer from any medical conditions?(required) Yes

If yes, please provide details including medications (e.g. asthma and requires Ventolin)

In the event of the emergency I give permission for Fernie School Aged Care to call an ambulance and I agree to incur all costs involved(required) Yes

Fernie School Aged Care Policies, Procedures and Guidelines

I have read and agree to adhere to the policies, procedures and guidelines in the Fernie School Aged Care Parent Handbook(required) Yes

Media Release

I give permission for Fernie School Aged Care to photograph my child for classroom, social media and local newspaper use(required) Yes

Field Trips

I give permission for my child to attend Fernie School Aged Care field trips (via foot and/or taxi transportation) to James White Park and within the local community. Field trips will occur regularly in all FSAC programs(required) Yes

Section 3

By entering my name below I agree that all information provided is true and correct at this time and I give consent for my child to participate in the Fernie School Aged Care School Break Summer Camp program

Parent / Guardian’s Full Name(required)

Date(required)

Child’s Information

Parent / Guardian Information (1)

Parent / Guardian Information (2)

Emergency Contact Information

Medical Information

Fernie School Aged Care Policies, Procedures and Guidelines

Media Release

Field Trips

Section 3

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