Required fields are marked with asterisks (*)

Camper Information Form

Thank you for choosing Day Camps at the Wilmot Recreation Complex! Please visit our Day Camps webpage for all information related to camp.

For additional children please ensure you click "yes" at the bottom of this page. At the completion of this form you will be asked if you have another child to complete forms for.

Primary Contact Information

This is the person who would be the initial contact in the event of an emergency; and provides direction for all things related to the camper(s).

Primary Contact First Name

Primary Contact Last Name

Home Address

Province

Postal Code

Primary Contact Home Phone Number

Primary Contact Work Phone Number

Primary Contact Cell Phone Number

Primary Contact Additional Phone Number

Primary Contact Personal Email Address

Primary Contact Work Email Address

Emergency Contact's Information

Please provide two additional Emergency Contacts in the event that the Primary Contact cannot be reached.

Emergency Contact #1 - First and Last Name

Emergency Contact #1 - Phone Number

Emergency Contact #2 - First and Last Name

Emergency Contact #2 - Phone Number

Program Arrival and Departure Permission

How will your child(ren) come and go from the program?

Please include three additional people whom are granted permission by the Primary Contact on this form that will be dropping off or picking up from the designed Programming Space.

My child(ren) will be dropped off or picked up by one of the following (photo ID may be requested by staff):

Person #1

Person #2

Person #3

Person #4

I understand that if somebody other than these individual(s) listed previously in this document is to pick up your child from the site, written consent will be required prior to releasing the child to the Supervisor of Recreation Programming or designate

Yes

AUTHORIZATION FOR PUBLICITY

The above mentioned participant(s) may appear in advertising/publicity arranged for by the Township of Wilmot, through various media outlets including but not limited to the television, radio, slide presentations, newspapers, and other print and electronic publications for the Township of Wilmot's promotions.

I agree to the previously stated Authorization for Publicity statement and agree to allow the Township of Wilmot to photograph the participants completed in this form.

Yes

EXCURSIONS OFF THE PROPERTY

The child(ren) listed on the form may occasionally leave the program premises with the staff for special outings within walking distance (eg. Picnics and Trails). Program staff members are not permitted to drive participants at any time during the program, for any reason. A notice will always be posted at the Wilmot Recreation Complex to indicate the whereabouts of your child as well as the expected time of return.

I agree to the previously stated Excursions for Off Property statement.

Yes

First Camper's Information

This is the first camper whom you are completing forms for. Additional campers are added upon completion of this information.

Child's First Name

Child's Last Name

Child's Hair Colour

Child's Eye Colour

Identifying Gender

Male

Female

Prefer not to say

Child's Age

Child's Birth Date

Child's Health Card Number

Camper Medical Information

This information is specifically for Camper #1. Additional information for other children attending camp will be asked in Camper #2 or #3 section.

Child's Doctors Name

Phone Number

Please list any and all medical conditions, health or learning concerns

Please list any Medical Information that is important for us to know for your child to be successful at camp

Does Your Child have any allergies we need to be aware of?

Yes

Are you sending any medication (ie. Benadryl) with your child to camp?

Yes

Does your Child require medication to be administered at camp?

Yes

Are there any special requests for your child that we need to be aware of?

Yes

Swimming

Summer camp includes swimming. Your child will swim 1 or 2 days a week depending on their age. This schedule will be provided for you at the start of the camp to allow you to pack the appropriate clothing for the day. Although swimming is planned this can change based on several factors. Please note that the low and medium groups will be required to wear a life jacket for the duration of the swimming time. The lifeguards are responsible for making the final say of what groups the children are in based on ratios, swimming ability and age, this is nonnegotiable. I understand that if behaviour has been an issue prior to swimming for safety reasons my child may sit out from swimming for the day.

Medications

As the parent/guardian of the named camper, that I request and authorize the oral administration to said camper of the prescribed medication referred to below, using procedures outlined below, by the Youth Engagement Programmer or Supervisor of Recreation Programming or their designate, who I acknowledge are not medically trained to administer medication.
I understand that no more than the prescribed dosage is to be sent to camp.
I understand and accept that if questions arise about administering the medication, the Supervisor of Recreation Programming or their designate, will contact the dispensing pharmacy to clarify the issue; for example, (including without limitation) whether there is a need to give the medication on an empty or full stomach.
I also understand and accept that if problems arise with the administration of the medications; for example, (including without limitations) refusal of medication by the camper to take medication, complaints of side effects, or possible allergic reaction, then the camp will immediately discontinue further doses and inform the primary contact at the earliest practical opportunity, as to the nature of the problem. It is then the primary contacts responsibility to decide if the camper’s physician needs to be consulted to assess whether changes to the prescribed medication need and/or administration procedures referred to below are necessary. A new copy of this Medical Administration form are required for any changes made.
I confirm that I have asked the camper’s physician if the medication must be administered during camp hours and he/she has advised so.
I understand that camp in not equiped to deal with complex medical issues and this may result in my child being withdrawn from camp.
I hereby release the Township of Wilmot, it’s employees and agents from all manner of action, causes of action, suits, losses, damages, or injuries, however caused, arising out of the administration or failure to administer medications as provided herein, and I do also hereby indemnify the Township of Wilmot, it’s employees and agents for any losses or damages sustained by them as a result of such actions or proceedings being commenced again them by myself or the camp or any other parent or guardian of said camper.

I hereby acknowledge that I have read and fully understand the terms set out herein as set out above in Medications.

Yes

Emergency Medical Treatment

Please read the following carfully.

In the event of an accident or illness involving my child while attending the program I hereby authorize, Township of Wilmot Staff (or their designate) to assist in the administering of all medication that is provided by the parents and/or guardians. Under no circumstances shall medication be provided without written or verbal consent from the primary contact.
I also understand and accept that the supervisor of Recreation Programming or their designate can reserve the right to refuse to administer treatment to the camper if the necessary information is not provided by the parent/guardian.
This information will be used to assist with the meeting of the health needs of camper.
If there are any questions about the information gathered on this form, please contact the Supervisor of Recreation Programming.
This request will terminate Labour Day Monday of each year.
I hereby release the Township of Wilmot, it’s employees and agents from all manner of action, causes of action, suits, losses, damages, or injuries, however caused, arising out of the administration or failure to administer medications as provided herein, and I do also hereby indemnify the Township of Wilmot, it’s employees and agents for any losses or damages sustained by them as a result of such actions or proceedings being commenced again them by myself or the camp or any other parent or guardian of said camper.
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 program staff (including aquatic staff).
I also give my permission for my child to be transported to the physician’s office of the Hospital Emergency Department with no liability on the driver’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 primary contact specified on the registration form.

I hereby acknowledge that I have read and fully understand the terms set out herein as set out above in Emergency Medical Treatment.

Yes

Zero Tolerance And Three Strike Rule - Camp Behavioural Managment

Please read the following carfully.

I understand there is a Zero Tolerance Rule at camp.

There will be no hitting, kicking, shoving, spitting, stealing, or damage of another person or their property while at camp. If this occurs, parents will be contacted immediately to come pick up their child and the child will not be welcomed back at camp or any aditional weeks after their first incident at the parent’s expense. No refunds will be issued.

I understand the three strike rule is for non-agressive incidence and is as follows

STRIKE 1:
- Notified at pick up of incident and ask parents to talk with their child about the rules of camp.
STRIKE 2:
- Document incident notify parents at pick up. Parents required to sign the bottom of document stating they understand this is the second strike if this happens again, they will be called in the middle of the day and must come in and pick up their child(ren).
STRIKE 3:
- A parent or gaurdian will be called and required to come pick up the child they will not be welcome back at camp or an aditional weeks.

I hereby acknowledge that I have read and fully understand the terms set out herein as set out above in Zero Tolerance And Three Strike Rule and I will be responsible to pick up my child if required

Yes

If an ambulance is called due to any emergency example the severity of an allergic reaction/ anaphylaxis reaction, I understand that the billing for the ambulance will be forwarded to the master contact specified on the registration form.

Yes

Is there a second child attending camp?

Yes

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