SuperKids Camp Registration Form 2017 CHILD'S INFORMATION Camper's First & Last Name (required) Gender (required) MaleFemale Street address (required) City (required) Province (required) Postal Code (required) Date of Birth (YYYY-MM-DD) (required) Age (required) Height (required) T-Shirt Size Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-LargeAdult XX-Large Weight (required) Shoe size (required) Has the camper attended SuperKids before? YesNo Can the camper swim in water over their head? YesNo Does this camper have any siblings registering for camp? (required) YesNo If so, please list their full names MEDICAL INFORMATION Name of Doctor (required) Doctor's Phone Number (required) Name of Dentist (required) Dentist's Phone Number (required) Medical Number (required) Does the camper have any allergies? (required) YesNo If yes, what are they and what is the camper's reaction? Does the camper have medical conditions, behavioral or emotional concerns? (required) YesNo Please explain all medical conditions and symptoms? Does the camper have food sensitivities? (required) YesNo If yes, what are they and what is the camper's reaction? List all medications the camper takes (one per line) I grant the designated CAMP NURSE permission to give my child over-the-counter medications if necessary (required) YesNo Parent/Guardian Initials (required) CONTACT INFORMATION Parent/Guardian First & Last Name (required) Phone Number (required) Email address (required) Emergency Contact #1 Full Name (first and last) (required) Phone Number (required) Emergency Contact #2 Full Name (first and last) (required) Phone Number (required) IMPORTANT FINANCIAL ASSISTANCE INFORMATION Social Assistance Recipients: If you are on social assistance, you need to apply IMMEDIATELY for your child's camp fee to be covered. Instructions and a downloadable letter are available on our SuperKids Camp page where the camp registration link is. If, after you have applied to social services and have given them enough time to process your request, you are denied, we will then consider an Extreme subsidy for your child. Written proof of the denial from social services is required. Low Income Single Parent Families: Through our fundraising efforts, Extreme Outreach endeavors to cover the camp fees of children from 'low income' single parent families who are 'not' on social assistance, as well as those who have been denied by social services their child's camp fee. If you are able to help by paying any amount towards your child's fee, we would appreciate it. If you select "yes" below when asked if you need financial assistance, you will be contacted by the EOS Office to discuss your situation. Documentation will be required. We welcome camp registration applications for children from all economic circumstances. If the notes above do not apply to you, then we require payment of the camp fee of $200 in full. Our SuperKids camp is the most inexpensive camp around as many other week-long overnight camps cost from $300-$500. We have kept the fee low in order to make it possible for every child to have the opportunity to come to camp! PAYMENT: After submitting this form you will be contacted by the EOS Office within 1 to 2 weeks to arrange payment. Do you need financial assistance (based on the notes above)? YesNo Are you currently on Government Social Assistance? YesNo APPLICANT'S STATEMENT I understand & agree PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR ACCEPTANCE MEDICAL RELEASE: I authorize the administration of any first aid treatment necessary at SuperKids Camp for my child. In the case of a medical emergency I authorize my child to be transported by designated leaders or arrange for transportation to the nearest medical or hospital facility. In such an emergency I hereby give permission to the physician involved to secure proper treatment for my child. In the event extraordinary transportation or medical treatment is required, I agree that Extreme Outreach cannot accept the financial responsibility. I expect to be contacted as soon as possible. LIABILITY WAIVER: I understand that Extreme Outreach is a Christian organization and that my child will be receiving Bible teaching at Super Kids Camp. Extreme Outreach reserves the right to dismiss a child who in their opinion is a hazard to the safety and the rights of others, or who appears to have rejected the camp rules as directed by the designated camp leaders. A child who must be sent home due to disciplinary action or home sickness must be picked up by a parent(s) or designated emergency contact. No refund will be given for a dismissal due to disciplinary action, home sickness, late arrival or early departure. I am confident that Extreme Outreach staff will do their best to give my child the necessary support and supervision needed and I understand that the safety and health rules will be observed. To the best of my knowledge, my child is in good health and physically, emotional, and socially able to participate in all camp activities. I give my child permission to participate in all camp activities. If my child is not physically, emotionally or socially able to participate in all camp activities, I understand that Extreme Outreach does not have the people for one on one with my child and they may be unable to attend camp. I give Camp staff permission to transport my child to and from Victoria to Camp Barnard, located in Sooke, BC. I hereby release Extreme Outreach Society and its personnel from all claims and damages arising from any accidents or injury caused by my child’s participation in the camp program or by transportation to and from camp. Extreme Outreach is not responsible for lost, stolen, or damaged items during my child’s participation at camp. I agree that photos or video of my child taken at SuperKids may be used in future Extreme Outreach and/or SuperKids promotional material. If I am not in agreement with this, I will give a written notice to Extreme Outreach that the photos and videos are not be used for this purpose. The parent/guardian submitting this application are those having legal custody over the child. Conditions of custody, if applicable, will be fully communicated in writing to the camp including a photocopy of the section of any court order referring to the visitation rights. Parent/Guardian Initials (required) Date (required)
