ArtWorth Registration Form 2018
ArtWorth -Trent Hills Art Camp - July 16 - 27, 2018
Email address *
REGISTRATION:
Which Camp are you Registering for? *
Name of Child I am Registering *
Your answer
PLEASE PROVIDE THE FOLLOWING CONFIDENTIAL INFORMATION:
Child's Health Card # *
Your answer
Child's Date of Birth *
Your answer
Child's Doctor’s Name *
Your answer
Child's Doctor’s Phone # *
Your answer
PARENT / GUARDIAN'S CONTACT INFORMATION:
Parent / Guardian's Name *
Your answer
Parent / Guardian's Email *
Your answer
Parent / Guardian's Mailing Address *
Your answer
Parent / Guardian's Primary Phone # *
Your answer
Parent / Guardian's Secondary Phone #
Your answer
ALTERNATE CONTACTS IN CASE OF EMERGENCY:
Alternate Contact 1's Name *
Your answer
Your Relationship to Alternate Contact 1 *
Your answer
Alternate Contact 1's Phone # *
Your answer
Alternate Contact 2's Name *
Your answer
Your Relationship to Alternate Contact 2 *
Your answer
Alternate Contact 2's Phone # *
Your answer
HEALTH INFORMATION:
Health Notes: Please be aware, continuing emotional or behavioural problems may result in the child being removed from classes at the discretion of staff. Also, we cannot guarantee an allergen free environment.
Does your child have any medical / developmental / physical / behavioural / emotional conditions or concerns? *
Your answer
Does your child take any on-going medication? *
If your child takes any on-going medication, please describe:
Your answer
Does your child have any life threatening allergies to medication / food / insect bites? *
If your child has any life threatening allergies, please describe and list reactions to watch for:
Your answer
Does your child carry an EPI Pen or ANA kit? *
Your answer
A copy of your responses will be emailed to the address you provided.
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