Pro-D Day & Spring Break Camps for Kindergarten - Grade 4

PRO-D DAY AND SPRING BREAK CAMPS FOR KINDERGARTEN – GRADE 6

Our licensed Before and After School Care program is pleased to be offering full day camps during Pro-D Day and Spring Break. Camps run 9 am to 3:30 pm, but we also offer an extended child care Before Camp (8:00-9 am) and after camp (3:30-6 pm) with no additional charges.

2020 APPLICATION FORM

I would like to register my child in the following camps:

Camps February 14 - Mission Impossible Camp March 16-20 - Amazing Race Camp March 23-27 - STEM Camp March 16-023 - Both Amazing Race & STEAM camp

Before Camp Care 8-9 am Feb 14 March 16-20 March 23-27 March 16-27

After Camp Care 3:30-6:00 pm Feb 14 March 16-20 March 23-27 March 16-27

CHILD'S PERSONAL INFORMATION

please complete a separate form for each child registering

Full Name of Child

Usual Name of Child (if different)

Grade

Date of Birth

Gender

Male Female

Address

IF YOUR CHILD IS NOT PRESENTLY ENROLLED IN THE BEFORE AND AFTER SCHOOL PROGRAM, YOU MUST COMPLETE ALL THE DETAILS BELOW:

(if your child is presently enrolled in the Before or After School Care program we will already have this information)

PARENT OR GUARDIAN INFORMATION

Mother / Guardian

Address (if different from above)

Phone

Employer

Work Telephone

Cell phone

Hours at this location

Father / Guardian

Address (if different than above)

Phone

Employer

Work Telephone

Cell phone

Hours at this location

ALTERNATE PERSON(S) AUTHORIZED TO PICK UP CHILD

(other than parent/guardian listed above, include emergency pickup) Check all that apply

Name of authorized individual #1

Relationship

Phone

Authorized to call in an emergency

Yes No

Name of authorized individual #2

Relationship

Phone

Authorized to call in an emergency

Yes No

Name of authorized individual #3

Relationship

Phone

Authorized to call in an emergency

Yes No

PERSON(S) THAT ARE NOT PERMITTED ACCESS TO MY CHILD

**Please note - if a parent of the child is on the NOT AUTHORIZED pick up list, a copy of a custody ordering must be supplied**

Name of individual #1

Relationship

Phone

Name of individual #2

Relationship

Phone

Custody Agreement

Yes No

Provided to Facility

Yes No N/A

CHILD'S IMMUNIZATION STATUS

copy provided to the Facility

Is your child up to date on immunizations?

Yes No Not Immunized

COMMENTS

HEALTH INFORMATION

Health professionals involved with your child (other than doctor and dentist):

Name of health professional #1

Profession/Agency

Phone

Name of health professional #2

Profession/Agency

Phone

Name of health professional #3

Profession/Agency

Phone

DOES YOUR CHILD HAVE:

A medical condition/concern? If yes, please provide further information:

Yes No

Allergies? If yes, please provide further information:

Yes No

Asthma? If yes, please provide further information:

Yes No

Has your child had a seizure in the past year? If yes, please provide further information:

Yes No

Food sensitivities? If yes, please provide further information:

Yes No

If Yes to any of the above, please provide further information:

List all prescription and “over the counter” medications your child receives:

Medication #1

Times Given

Reason for Medication

Medication #2

Times Given

Reason for Medication

Medication #3

Times Given

Reason for Medication

EMERGENCY HEALTH INFORMATION

Care Card Number/Personal Health Number

Family Doctor / Clinic Name

Doctor / Clinic Telephone

Dentist / Clinic Name

Dentist / Clinic Telephone

CONSENT FOR EMERGENCY CARE

I authorize the staff at Deer Lake School Before and After School Care to call a medical practitioner or ambulance/transport child to emergency medical care, in the case of accident or illness of my child if the parent cannot immediately be reached.

Yes No