Summer Day Camp 2012 Application PDF ~ Please complete and mail/email to church
SUMMER DAY CAMP 2012
Please check off the program and periods you are interested in.
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August 13 to 17 |
Half Day $30/week 8:45 am – 11:45 am |
(3-5 years old) |
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August 20 – 24 |
Full day $60/week 8:45 am – 3:00 pm |
Option One (5 – 11 years old) |
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August 20 – 24 |
Full day $75/week 8:45 am – 4:30 pm |
Option Two (5 – 11 years old) |
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Summer Day Camp is for children between the ages of 3 and 11 |
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Contact: Sharon MacDonald 250-388-5188 ext 221 |
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Name (Last, First): ________________________________________
Address (Street, City Prov PC): ____________________________________
Telephone: _________________________________________
Email: _______________________________________
Date of Birth: _________________________________________
Gender (circle one): M F
Last Grade Completed: ________________________________________
Child’s Health Care #: ________________________________________
Family Doctor & Phone: ________________________________________
Mother’s Name: _________________________________________
Mother’s Place of Work: ________________________________________
Mother’s Work Phone: ________________________________________
Father’s Name: _________________________________________
Father’s Place of Work: ________________________________________
Father’s Work Phone: ________________________________________
WE WILL NOT release your child to anyone besides yourself without your consent in writing. Please list alternate person (s) that may pick up your child or who we may contact in case of emergency.
Name Relationship to Child Telephone
Name Relationship to Child Telephone
Please list any precautions or health concerns/problems that we need to be aware of:
PARENT / LEGAL GUARDIAN MEDICAL CONSENT AND AGREEMENT
Your signature gives permission for the following:
In case of medical emergency, children will be transported to the nearest emergency facility for treatment.
- Field Trips which require this child to away from the church.
- Photos may be taken of children in programs and may be used in displays and promotional materials including website. No name will appear with photos.
We (child and parent) understand that it is the responsibility of each participant to participate in the whole program. We recognize that children must follow safety instructions, remain in areas designated by staff, and refrain from behavior that is harmful to oneself and others or property. Failure to adhere to these policies will be the cause for your child’s dismissal without refund of program fees.
________________________ _______________
Parent/Guardian Signature Date
? I would like to receive information on upcoming workshops or events.
PAYMENT RECORD
Registered for Full day or Half Day Date _____________
Total Fee $_____________ Paid __________ Balance Owing $________
Paid $_____________Cheque or cash_____________ Date _______________
Paid $_____________Cheque or cash_____________ Date _______________
Paid $_____________Cheque or cash_____________ Date _______________
Fees must be paid in full seven days prior to each session, unless other arrangements have been made with the coordinator.
First†Metropolitan United Church
932 Balmoral Road, Victoria BC V8T 1A8
Telephone: 250-388-5188 Fax: 250-388-5186
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