Summer Kids Computer Day Camp 2010

The QUEST Centre Registration Form: Registration deadline: One week before session starts

Child’s First Name

Child’s Last Name

Gender

Grade

Age

Date of Birth mm dd yy

Session 1   July 12-16                   Pioneer Week
  Session 2   July 19-23               Knights of the Round Table
  Session 3   July 26-30               Mad Science
  Session 4   August 3-6    Rocks ‘N Stuff 
  Session 5   August 10-14               Arts & Crafts

Session 1, 2, 3, & 5: $140/ wk/child    Family Rate: Each additional child: $115/week 
Session 4: $115/wk/child                      Family Rate: Each additional child: $90/week

Children are required to bring a lunch and a drink except on Friday when it will be provided

The Summer Kid’s Camp will provide light snacks and indoor/outdoor activities with a focus on computer fun.

Mother/Guardian’s Name:_____________________ Phone #: Home___________________ Work______________________

______________________________________________________________________________________________________________

Address City/Town Postal Code

Father/Guardian’s Name:______________________ Phone #:Home _______________________Work__________________

______________________________________________________________________________________________________________

Address City/Town Postal Code

If parents cannot be reached, additional people your child(ren) may be released to:

1. Name_________________________________________________ Phone # ________________________________

2. Name_________________________________________________ Phone # ________________________________

In case of emergency, if parents cannot be reached, who can we contact?

1. Name_________________________________________________ Phone # ________________________________

2. Name_________________________________________________ Phone # _______________________________

Name of Family Doctor _______________________ Phone # ___________________ OHIP # ______________________

Does your child have any allergies? Yes / No If yes, please list___________________________________________

Are there any medical/physical conditions? Yes / No If yes, please explain_____________________________________

Are there any special requirements? Yes / No If yes, please explain______________________________________

I hereby give my permission for my child(ren) to be treated by a physician or hospital staff member should there be an

accident, sudden illness or emergency. Yes / No

Parent/Guardian Signature: ________________________________________ Date:________________________

• To ensure safety and fun for all, the director of the program reserves the right to withdraw anyone from the program

who destroys public property, injures another participant, or refuses to cooperate with the camp leader.