AGO/OCAD ART AND DESIGN CAMP REGISTRATION FORM Summer 2011 This form must be completed and received by the Group Sales Office with payment PRIOR TO the start of camp. Registration is NOT confirmed until we have your camper forms and payment. Please complete all 5 pages. CAMP NAME SESSION (1, 2, 3, 4, 5) Camper s Name: Age Date of Birth Gender: M F Day Month Year HEALTH CARD NUMBER: Address (while attending camp) City Postal Code E-mail address _ 1 st Parent/Guardian Name: Hm # Cell # Wk # ext. Best contact # Hm Wk Cell 2 nd Parent/Guardian Name: Hm # Cell # Wk # ext. Best contact # Hm Wk Cell AGO/OCAD summer camp 2011 camper information form 1
MEDICAL INFORMATION Does your camper have any allergies? No Yes Specify allergy: *Please specify in detail on page 4 Does your camper require an EPI-PEN? No Yes If yes, you MUST fill out page 3 and sign the parental consent form available at the registration table. Will your camper be carrying or requiring any medication to be taken/administered at camp? No Yes (Please specify) _ Does this camper have any other health or behavioral conditions we should know about? Is there anything you would like us to know to help enrich your campers time at camp? We may contact you to fill out a questionnaire to assist us as follow up. (All information will be held in strict confidence. Information shared promotes a more positive camp experience). DROP OFF/PICK UP INFORMATION This camper will only be released to the Parent/Guardians listed above and the individuals listed below. Personal photo identification will be required when picking up the camper. 1. Check here if person #1 is also an emergency contact (see below) 2. My child may leave camp by him/herself No Yes My child is enrolled in pre/aftercare No Yes AGO/OCAD summer camp 2011 camper information form 2
EMERGENCY CONTACT INFORMATION List here the 2 required emergency contacts for this camper in the event that Parents/Guardians cannot be reached. 1. 2. I understand that, in registering for camp, my child will be involved in physical activities and that, with any physical activity, there is risk of injury. In the event of an emergency, I authorize the physician in the emergency care unit selected by the Art Gallery of Ontario/Ontario College of Art and Design staff to secure proper treatment for the child indicated above. I also authorize photography of the above named child, or any artwork he/she produces as part of the Art Camp program, for Art Gallery of Ontario and/or Ontario College of Art and Design archival documentation purposes and to authorize publication of this material in any media for promotional or educational purposes. I agree to the above terms and have ensured that all the information given is accurate and up to date and that if there are any changes that it is my responsibility to inform the Art Gallery of Ontario. _ SIGNATURE of Parent/legal guardian date AGO/OCAD summer camp 2011 camper information form 3
ALLERGY INFORMATION SHEET You are required to fill out this sheet if your child has a known or suspected allergy and is at risk for allergic complications and/or anaphylaxis. Name of Camper Date of Birth EpiPen Location: 2nd EpiPen Carried? yes no You must fill out the Parental EpiPen consent form on page 5, (also available at the registration table), if your camper carries an EpiPen to camp. Allergy Description This child has a dangerous Life-threatening allergy to the following substances: 1: 2: 3: 4: This child will react to the above listed substances upon Inhalation contact Ingestion Please list any detailed information about your childs allergy: Symptoms (known) specific to your child (0 15 minutes after consumption or contact) Any other medication to be given, with specific instructions: Camper s Doctor Name Doctor s phone # Doctor s pager # AGO/OCAD summer camp 2011 camper information form 4
EPIPEN CONSENT Please complete and sign the following if your child will be carrying an Epi-pen to camp with them: AGO/OCAD CAMP 2011 PARENTAL CONSENT FOR EPIPEN USE ------------------------------------------------------------------------------------------------------------------- In the event of an emergency, I,, give permission for an (Parent/Legal Guardian-print name) AGO/OCAD Staff Member trained in Emergency procedures and First Aid to assist my child (Print name) in administering their personal EpiPen. Parent/Legal Guardian Name Parent/Legal Guardian Signature Date AGO/OCAD summer camp 2011 camper information form 5