CAMP PROMISE AFTER SCHOOL PROGRAM APPLICATION FORMPROGRAM

NAMECAMP PROMISE AFTER SCHOOL PROGRAM Fall 2017- Spring 2018

Program Bethel Community ChurchLocation128 St Vincent Street Barrie, ON L4M 3Y8

Program Time3:30pm –5:30pm Wednesdays, Thursdays, Fridays

Start Date Wednesday September 13, 2017 End Date: Thursday May 17, 2018 Cost Free

Meet: At Program Location above OR We Pick Up the children at Codrington and Oakley Park Schools at 3:20pm.

Contact Person Camp Director: Tracy Robinson

PLEASE BRING HOME WORK AND ANY COMMUNICATION BOOK USED WITH CLASSROOM TEACHER

APPLICATIONSCANNOTBEACCEPTEDIFINCOMPLETE.PRINTCLEARLYINBLUEORBLACKINK

CHILD/YOUTHINFORMATION

LastName FirstName M.I.

Date ofBirth D M Y Age Gender MALE FEMALE

Health Card Number(Required)

Medical Conditions orAllergies

Special Needs (i.e.ADD/ADHD, Autism, LearningDisabilities)Name ofSchool Grade Name ofTeacher

PARENT/GUARDIANINFORMATION

LastName FirstName M.I.

StreetAddress Apartment/Unit#

City Province PostalCode

HomePhone ( ) E-mailAddress

CellPhone ( ) OtherPhone ( )

EMERGENCYCONTACT

LastName FirstName M.I.

HomePhone ( ) CellPhone ( ) Relationshipto child/youth

AlternateContact

HomePhone ( ) CellPhone ( ) Relationshipto child/youth

ACKNOWLEDGEMENTIherebygrantpermission formychildtoparticipate inalltheactivitiesof thisprogram (whichmayincludeoutingsduringprogram hours)andrelease Camp Promise and staff from any and all liability, claims, demands, personal injury, sickness, death, as well as property damage and expenses ofanynaturewhatsoever,whichmaybeincurredbythechildparticipant.FurtherIgrantpermissiontoCamp Promisestafftoauthorizemedicalpersonnelto carryoutanyemergencyprocedureonmychildinthe casethatI,ormyemergencycontact,cannotbereached atthetimeoftheincident.Inaddition,I understandthatphotographs/videoofmychildtakenduringprogrammaybeusedforpromotionalmaterial.I havereadandunderstoodthiswaiver.

Parent/GuardianSignature Date

camppromise@bethelbarrie.ca 128 St. Vincent Street Barrie, ON L4M 3Y8 Tel:705-726-9778 Fax:705-722-5082

RegisteredwiththeCanadaRevenueAgencyRegistrationNo.128793049RR0001