Youth Programming Card Application

The youth programmign card is valid for youth Grades 4 through 12 for programs offered within the Township of Wilmot from July 1st to June 30th annually.

This application must be filled out prior to attendance at the Youth Centre and Open Gym.

To add additional children, please click "yes" at the bottom of this page. 

Primary Contact Information

This is the initial contact person we call in the event of an emergency and provides direction for all things related to the child(ren). 

Emergency Contact's Information

Please provide two additional emergency contacts in the event that the primary contact cannot be reached.

Program Arrival and Departure Permission

Listed below are people authorized to drop-off and pick-up your child. Your child will not be released to anyone unless they are listed below. PLEASE LIST YOURSELF, and three additional people including relatives, guardians, friends etc. whom you as the primary contact grant permission to drop off or pick up your child(ren) from the designated programming space. In an effort to ensure the safety of your child, you or whoever is picking up the child may be asked to show a picture I.D. Please make sure to inform the individual picking up your child of this policy to avoid any confusion or frustration at the time of pick-up. Thank you for your cooperation.

 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(ren) to the Supervisor of Recreation Programming.

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. 

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.

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.

Travel Home Alone Authorization

In order for your youth grades seven (7) through (12) to travel home independently from the Optimist Youth Centre and or Township of Wilmot owned buildings from recreational programming offered by/or with the Township of Wilmot where the Youth Programming Card is required for participation, it is necessary for you to sign this form and submit it to the Supervisor of Recreation Programming along with the Application form. We will ensure your child’s safety during the hours of programs but are not responsible once they leave and sign themselves out; and as parents you understand that certain risks are present when travelling home alone or catching a bus.

First Child's Information

This is the first child for which you are completing forms for. Additional children are added upon completion of this information. 

Medical Information

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

Medications

1. 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 above, using procedures outlined, by the Summer Day Camp Coordinator or Supervisor of Recreation Programming or their designate, who I acknowledge are not medically trained to administer medication.
2. I understand that no more than the prescribed dosage is to be sent to camp.
3. I understand and accept that if questions arise about administering the medication, the Supervisor of Recreation Programming or thier 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.
4. 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 contact's 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 above are necessary. A new copy of this Medical Administration form are required for any changes made.
5. I confirm that I have asked the camper’s physician if the medication must be administered during camp hours and they have advised so.

Emergency Medical Treatment

Please read the following carfully.

1. In the event of an accident or illness involving my child while attending the program I hereby authorize the Program Coordinators and the Supervisor of Recreation Programming (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.
2. I also understand and accept that the supervisor of Recreation Programming can reserve the right to refuse to administer treatment to the camper if the necessary information is not provided by the parent/guardian.
3. This information will be used to assist with the meeting of the health needs of camper.
4. If there are any questions about the information gathered on this form, please contact the Supervisor of Recreation Programming.
5. This request will terminate upon the yearly expiration of Youth Programming Card Information.
6. 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 against them by myself or the program or any other parent or guardian of said participant.
7. 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.