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CAMP PROMISE AFTER SCHOOL PROGRAM APPLICATION FORM PROGRAM NAME CAMP PROMISE AFTER SCHOOL PROGRAM Fall 2017- Spring 2018 Program Bethel Community Church Location128 St Vincent Street Barrie, ON L4M 3Y8 Program Time 3:30pm –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, 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 ( ) Relationsh ipto AlternateContact HomePhone ( ) CellPhone ( ) Relationsh ipto ACKNOWLEDGEMENT Iherebygrantpermission 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 Parent/GuardianSignature Date [email protected] 128 St. Vincent Street Barrie, ON L4M 3Y8 Tel:705-726-9778 Fax:705-722-5082 RegisteredwiththeCanadaRevenueAgency
