Divine Care Academy Summer Day Camp Program
45 Atherton Crescent 
Keswick, Ontario
Admin@dcacanada.com
(647) 773-8777

Name of Child(ren): ______________________________________________ Age ________

			________________________________________________ Age ________

			________________________________________________ Age ________

Participant Genders: Male ____ Female ____ 
			   Male ____ Female ____ 
			   Male ____ Female ____ 

Name of Parent/Guardian: ______________________________ Relation _______________
			
				   ______________________________ Relation _______________

				   ______________________________ Relation _______________

Is the participant born before January 2021? # _________

Part-Time Enrolment (Tuesday, Wednesday, & Thursday)	____
Full-Time Enrolment (Monday to Friday)				____
Extended Before Care (6:45 am – 8:00 am)				____
Extended After Care (6:30 pm – 8:00 pm)				____
Extended Before and After Care 					____
Single Days (Can only book week before)				____	
	
Select Dates:

June 21st - 25th _____
June 28th - July 2nd _____ -$55.00 Holiday July 1st
July 5th - 9th _____
July 12th - 16th _____
July 19th - 23rd _____
July 26th - 30th _____
August 2nd - 6th _____ -$55.00 Holiday August 2nd 
August 9th - 13th _____
August 16th - 20th _____
August 23rd - 27th _____
August 30th - 3rd _____

General Inquires 

Is the participant under any form of treatment for an illness, condition or injury? ___

Does the participant have any medical or behavioral conditions that we should prepare for? ________ if YES, please take a moment to explain how we can help you:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Does the participant use anything for asthmas? ______ Medication ________________

Does the participant use or carry an Epi-pen? _____ if yes, for: _____________________

Does the participant wear a Medic-Alert bracelet? _____ if yes, for: _________________

Contact Information

Main Contact

Name: _____________________________________________ Relation _____________________ 

Address: ____________________________________________ Postal Code: _______________

City/Province: _______________________________________ Contact: ___________________

Email: ____________________________________ Second Contact #: ____________________

Alternative Contact

Name: _____________________________________________ Relation _____________________ 

Address: ____________________________________________ Postal Code: _______________

City/Province: _______________________________________ Contact: ___________________

Email: ____________________________________ Second Contact #: ____________________

Emergency/Alternative Pick Up

This is a person over the age of 16 who is authorized to pick up your child and can be contacted by Care Camp (also known as Divine Care Academy Care Camp) staff when the parent/guardian cannot be reached.

Name: ______________________________________ Primary Contact: ___________________

Relationship to participant: ___________________ Secondary Contact: ________________

Code of Contact

The safety of everyone in the program is of the most important to us at Care Camp. Each registrant must recognize a personal responsibility to9 learn and always follow the safety and other rules established by Care Camp staff. I hereby agree that any behaviour of the participant that places him/herself or others at risk may result in the participant's immediate dismissal from the program. Further, if dismissed from the program, I agree to cover any expenses arising from such dismissal. I hereby acknowledge and agree that no refund will be granted for the dismissal or removal of the participant at his/her request before the end of the program session. To ensure the safety and well-being of all individuals participating in the program, Care Camp reserves the right to alter the program at any time without notice or compensation to the registrant. 

_________ Please Initial 

Assumption of Risk and Indemnifying Release

While Care Camp staff and instructors will make every effort to minimize exposure to known risks associated with each registrant (defined below) participation in the Care Camp program, I hereby acknowledge that I and/or my child, if registering on his/her behalf (collectivity, the "	Registrant") may be required, depending on the nature of the program, to participate in various physical activities that may involve risk of injury. In this regard, I agree that I have provided (if required) a complete and accurate health history and hereby permit the Registrant to participate in the full range of the Program activities, except as specifically noted by me in the health information section of the program registrant (where applicable). 

In consideration for the Registrant's opportunity to participate in the Program, the receipt and sufficiency of which is hereby acknowledged, I hereby release and forever discharge Care Camp, it's respective officers, director, employees, volunteers and agents, and their respective successors and assigns, from any and all liability for damages sustained in consequence of loss, injury or damage to the Registrant, and from all other actions, causes, claims, demands or damages of any kind with respect to death, injury, loss or damages to any person or property arising out of connected with preparation for, or participation in, the Program.

_______ Please Initial

Medical Emergencies 

In the event of an accident, injury or illness involving the registrant, and immediate contact by Care Camp with a designated contact cannot be made, I hereby authorize and grant permission to Care Camp staff to ensure a secure and proper medical treatment and authorize on the registrant's behalf all procedures, including, without limitation, admission to an emergency unit, hospital and treatment therein, ordering of x-rays, tests or treatment, injections, anesthesia and/or surgery, as deemed necessary by the attending medical professional(s). I agree not to hold Care Camp responsible for any cost or injury arising out of an emergency.

__________ Please Initial

Commitment to Privacy 

Care Camp is committed to protecting personal information by following responsible handling practices. We collect and use information you volunteer when you access or register for the Care Camp program, to better meet your service needs, to ensure a safe environment, for statistical and assessment purposes, to inform you about the Program in which you are registered, and to satisfy ministry and regulatory requirements. You may also hear from us periodically about other Divine Care Academy programs, services and opportunities that may6 interest and benefit you.

________ Please Initial 

Consent Form for Filming/ Photography 

I hereby consent to Care Camp using images of my above named child caught in video recordings, and/or photographs on to be sent to the parents and also being used for marketing and publicity-related purposes and used in Care Camp's publications and I understand that they may be published on Divine Care Academy's website, social media platforms or another website. I understand that their images will be held in accordance with the Data Protection  Act; that the images of my child(ren) captured in the video recording and/or photographs will be the copyright of Care Camp. My child and I hereby agree to waive all moral rights in my performance in the film and/or recordings to Care Camp. I also understand that I can ask Care Camp to stop using my child's images at any time, in which case they will not be used in future publications but may continue to appear in publications already in circulation.

_________ Please Initial 

Registrant Agreement 

By signing my name, I (or my legal guardian) acknowledge that I (or we) have carefully read and understand the Code of Conduct, Assumption of Risk, Indemnifying Release Statement, Medical Emergencies Statement, and commitment to Privacy Statement.

Full Name: _________________________________ Signature: ______________________ Date: ___________

Full Name: _________________________________ Signature: ______________________ Date: ___________

Documents to Complete 

Registration Form
Medical Form including Non-prescription form
List of allergies and Food Restrictions including the Allergy Card 
What to bring list
Sunscreen Permission Form
Emergency Package (for lost children)
Direct Deposit From
Parent Agreement Contract
Cross out when completed 

Admission: _________________________________ Signature: ______________________ Date: ___________

Director: ___________________________________ Signature: ______________________ Date: ___________