Nature School and Education Centre
                                                Summer Camp Registration Form
                About Child
                Name:                    ,                    ,                     Age: 
                                                                                                          Birthdate:
                Mailing address: 
                Home address (if different from mailing) 
                Session Dates
                $150/week or $35 a day
                                                         Select weeks       Before care        After care 
                                                                            required?          required?
                1     July 4-8 
                2     July 11-15 
                3     July 18-22 
                4     July 25-29 
                5     Aug 2-5 (4 days, $120 week
                6     Aug 8-12 
                Extended care rates:
                $5 8AM-9AM 
                $5 4PM-5PM 
                available as needed  
                10% discount for siblings, I am registering more than one sibling ☐
               Parent/Guardian - Contact Information 
               Name:                     
               Home address (if different from child) 
               Primary phone number:                              Alternate number: 
               Work number:                         Email: 
               Name:                     
               Home address (if different from child) 
               Primary phone number:                              Alternate number: 
               Work number:                         Email: 
               Emergency Contact Info
               Please contact this person first (after contacting guardians):
               Name:                     
               Relationship to child 
               Primary phone number:                              Alternate number: 
               Work number:                         Email: 
               2nd emergency contact information
               Name:                     
               Relationship to child 
               Primary phone number:                              Alternate number: 
               Work number:                         Email: 
                Please list those people including in addition to parents/guardians who are permitted to pick up your 
                child: 
                Medical Release Information 
                Health card number: 
                Primary Physician:                              Phone number: 
                Address: 
                Please list any medical problems, including any requiring maintenance medication (i.e.
                Diabetic, Asthma, Seizures). 
                Is your child presently being treated for an injury or sickness, or taking any form of medication for any 
                reason?
                Yes ☐   No ☐   
                If yes, explain:
                 
                Is your child allergic to any type of food or medication? 
                Yes ☐   No ☐   
                If yes, explain
                I understand that I will be notified in the case of a medical emergency involving my child. In the event 
                that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical 
                services in the event my child is injured or becomes ill. 
                Parent’s/Guardian’s Initials:                        
                I understand that Nature School and Education Centre will not be responsible for the medical expenses 
                incurred, but that such expenses will be my responsibility as parent/guardian. 
                Parent’s/Guardian’s Initials:                        
                Please circle (indicate) how you heard about Nature School and Education Centre 
                ☐Website
                ☐ School
                ☐ Word of Mouth
                ☐ Community Event 
                ☐ Flyer/ Pamphlet 
                ☐ Facebook 
                ☐ Other:                   
                Terms of Agreement 
                Photo Release (optional)
                I hereby give permission for my child to be photographed during the Nature School and Education 
                Centre Day Camp. I understand the photos will be used to keep a journal of activities, to share during 
                power point presentations and/or reports to our donors and for promotional purposes including flyers, 
                brochures, newspaper and on the internet. I understand that although my child’s photograph may be used 
                for advertising, his or her identity will not be disclosed, I do not expect compensation and that 
                all photos are the property of Niagara School and Education Centre and its affiliates. 
                Parent’s/Guardian’s Initials:                    
                Transportation Release 
                I hereby give permission for the transportation of my child for official Nature School and Education 
                Centre- Day Camp activities by modes of transportation agreed to by the camp organizers. 
                Parent’s/Guardian’s Initials:                    
                Nature School and Education Centre and its co-organizers are not responsible for lost or damaged 
                personal property.