PA DAY CAMP REGISTRATION FORM PA DAY CAMP REGISTRATION FORM * April 8, 2024 June 7, 2024 June 28, 2024 After Care 3pm - 4pm ($12) Parent/ Guardian Name * First Last Address: * Phone Number * Email Address * Child Name * First Last Age (4-7) * — Select — 4 5 6 7 - Age (8-11) * — Select — 8 9 10 11 - Gender * — Select — Female Male Child Name 2 First Last Age (4-7) — Select — 4 5 6 7 - Age (8-11) — Select — 8 9 10 11 - Gender — Select — Female Male Emergency Contact Name & Phone Number * Doctor's Name and Phone Number * Health Card Information - Child #1 * Health Card Information - Child #2 Medical Concerns Does your child have any allergies, medical concerns, or food restrictions that we should be aware of? * — Select — N/A Child 1 - Yes Child 2 - Yes Both Child 1 & 2 - Yes If any please tell me about them here Does your child carry an EpiPen? * — Select — N/A Child 1 - Yes Child 2 - Yes Child 1 & 2 - Yes Anything else you would like to tell us ? Informed consent agreement: Print Your Name and the date * I, the undersigned, hereby agree to indemnify and save harmless Willowjays Co. of Sunderland, their/ its employees, members and coaches from all claims, demands, damages, actions, suits or proceedings arising out of participation of myself/my child, named above, in any activity. I, the undersigned, hereby acknowledge that certain risks of injury are inherent to participation in hand on science, arts & crafts, outdoor play and physical activity. These types of injuries may be minor or serious and may result from one’s own actions, or the actions of others, or combination of both. I, hereby warrant that my child is physically fit and medically capable to participate and understand that the choice to participate brings with it the assumption of those risks and results which are part of the activities held at Willowjays. I agree to allow my child to receive basic first aid/ medical care from the instructors certified in first aid if necessary. Willowjays has my permission to use pictures and quotes for promotional material in print and electronic format, including to their website or other social media platforms. If you do not wish for your child’s photograph to be taken please notify Willowjays in writing. I declare having read and understand the above informed consent agreement in its entirely and hereby consent to participate acknowledging all the foregoing. I also certify that the information provided above in this form is true and correct. I hereby grant permission for Willowjays to use photos and/ or videos of my child for the use of promotional material. * I give consent for my child to be photographed for promotional purposes I do not give permission for my child to be photographed Where We Are 10430 Sideroad 17 Sunderland, ON L0C 1H0
