Manitoba Day Camp Registration 2024

Camper Information

General Information

First Name

Last Name

Date of Birth

Age

Home Address

Please select which week your camper will be attending

July 15-19, Community Roots Resource Centre

Medical Information

9 digit MB Health Number

Family Doctor

Family Doctor Phone Number

Does your child have any Health Concerns? (Social, emotional, physical, medical, behavioural, developmental, or otherwise?) Please explain. Any information will help us to support your child.

Does your child have any Allergies? Please explain.

Does your child carry an Epipen?

YesNo

Does your child have any dietary restrictions? Please list them below.

Media Consent

I hereby grant A Rocha Canada (ARC) the absolute right and permission to use, re-use and distribute, without financial consideration, photographs, video and/or audio of my child (named above) in any and all media, in perpetuity.

I also consent to the use by ARC of my child's (named above) personal story for use in any media.

YesNo

Parent/Guardian Name (First and Last)

This will act as an electronic signature, confirming that you have
read and agree to the terms above.

Date

Liability Waiver

I give permission for my child to participate in the activities organized by A Rocha Canada. In the event of a medical emergency, I understand that an effort will be made to reach me. However, I do give permission for the staff of this program to authorize emergency medical care for my child. I understand the risks involved in this program and that the staff will exercise all reasonable care for my child. I will not hold A Rocha Canada or other co-operating organizations, their staff or representatives, responsible for any injuries that may be sustained by my child.

I understand that A Rocha Canada is not responsible for my child until and unless they arrive at the program site.

Parent/Guardian Name (First and Last)

This will act as an electronic signature, confirming that you have
read and agree to the terms above.

Date

Registering another Camper?

If you are registering more than one camper in the same family, they must share the same Family Information below, including Primary Parent/Guardian, Second Parent/Guardian and Emergency Contact.

Family Information

Primary Parent/Guardian

First and Last Name

Relation to the Camper

Phone Number

Secondary Phone Number

This email will receive all communication
and important program announcements.

Yes, I want hopeful creation care news in my inbox every month!

Home Address

Second Parent/Guardian or Emergency Contact

In case of emergency, where the Primary Parent/Guardian cannot be reached, this person will be contacted.

First and Last Name

Relation to the Camper

Phone Number

Secondary Phone Number

Carpooling?

Please list the names (First and Last) of any adults not mentioned above who are allowed to pick up your child(ren) after class.

Health and Wellness Agreement

As the Parent/ Guardian of a Day camp attendee, I understand and commit to the following:

1. I will assess my child(ren) before the program for cold, flu, or COVID-19- like symptoms, even mild ones, such as fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue, and loss of appetite. I will also assess for other contagious illness related symptoms such as stomach flu and pink eye. I will commit to keep my child home if any of these symptoms are present. (I will call Healthlinks or visit Shared Health if I have any questions regarding symptoms).

2. Should my child(ren) develop symptoms while at camp, I will ensure someone is available to pick them up promptly if we are contacted by the staff to do so.

Parent/Guardian Name (First and Last)

This will act as an electronic signature, confirming that you have
read and agree to the terms above.

Date

Confirmation

By submitting your name (first and last) below — as an electronic signature — you, as the parent or legal guardian of the child(ren) being registered, confirm that the information above is accurate.

Contact Information