Rotary Summer Literacy Registration 2018
Rotary Club of Hamilton's Free Summer Literacy Program complete the form below to register your child. A separate form must be completed for every child registered.
Email address *
Child's last name *
Your answer
Child's First Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Child's Address *
Your answer
City *
Your answer
Postal Code *
Your answer
Phone Number *
Your answer
Primary Email Address *
Your answer
Child's Grade in September *
Custody *
Parent/Guardian's Name *
Your answer
Day Phone Number *
Your answer
Cell Number *
Your answer
Name of person authorized to pick up child other than parents/guardians. *
Your answer
Authorized Person's phone number. *
Your answer
Name of person authorized to pick up child other than parents/guardians. *
Your answer
Authorized Person's Phone Number *
Your answer
#1 Emergency Contact Name *
Your answer
#1 Emergency Contact Daytime Phone Number *
Your answer
#1 Emergency Contact Cell Number *
Your answer
#2 Emergency Contact Name *
Your answer
#2 Emergency Contact Daytime Phone Number *
Your answer
#2 Emergency Contact Cell Number *
Your answer
Family Physician *
Your answer
Family Physician Phone Number *
Your answer
Please indicate if your child has had any difficulties with the following: *
Required
Does your child have an inhaler? *
Does your child have an EPI Pen? *
Is there any other information you feel we need to know about child? *
Your answer
Please indicate which session(s) you would like your child to attend in order of preference (1,2,3)
If you would like your child to attend all sessions, please mark each with 1. If your child is not available for a session please mark it a 0. Please only mark each session once.
Space in the Rotary Summer Literacy Program is limited.
Session #1 Back to the Future - July 16th to 20th, 2018 9:00 am to 2:15 pm *
Join us for an exciting adventure across Canada and through time as we explore Canada's past, present and future.
Not Available
Last Choice
Session #2 Dreams Come True - July 23rd to 27th, 2018 9:00 am to 2:15 pm *
Fairies, knights, princesses, dragons and magical lands await!
Not Available
Last Choice
Session #3 Camp Rocks - July 30th to August 3rd, 2018 9:00 am to 2:15 pm *
Walk the Red Carpet in style! This week we will be whoever we want to be: rock star, author, artist, just to name a few.
Not Available
Last Choice
Afternoon Program Options *
Please check activities your child would be interested in participating in during program option time.
Required
Rotary Summer Literacy Registration Waivers
If at any time emergency medical treatment is necessary for my child, I give my consent for treatment to be given. Every effort will be made to contact parent/guardian(s) and or emergency contacts. *
Rotary Summer Literacy may decline participation of a participant due to physical and/or verbal abuse towards our program participants, staff, and parents. *
Every Rotary Summer Literacy participant that requires an inhaler or EPI Pen needs to have it on his/her person at all times. *
I understand and give consent that any photographs taken by Rotary Summer Literacy may appear on the Rotary website, blog, and other promotional materials. *
Name of the person completing this form. *
Your answer
A copy of your responses will be emailed to the address you provided.
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