Language Adventures Registration Form- Facilitated by Anish Healing Centre

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Kindly enter all applicable participant info, form must be completed to complete registration process

Which Program are you registering for? *

Ages 5-12 Language Adventures July 2025

Other:

EMAIL FOR CAMP DETAILS FOLLOWING APPROVAL *

Child's First Name *

Child's Last Name *

Child's Birth Date *

YYYY

Child's Gender *

Male

Female

Prefer not to say

Other:

Will participants have other siblings registering for the same program? *

yes (Please record names below)

Names of siblings also registering (note-each child must have a registration form filled out) *

Child's Home Address

Manitoba Health Registration # (6 digits) *

Child's Manitoba Health ID # (9 Digits) *

Child's Emergency Contact # 1 Full Name *

Child's Emergency Contact #1 Phone Number *

Child's Emergency Contact #2 Full Name *

Child's Emergency #2 Phone Number *

Please provide full names and phone numbers for guardians who have consent to pick up your child. *

Allergies/Medications *

No Known Allergies

Allergy, requires EpiPen (please provide details below)

Allergy, does not require EpiPen (please provide details below)

On Medication (please provide details below)

Medication Administration Required during Programming (please provide details below)

Other Medical concerns we should be made aware of (please provide details below)

Other:

Allergy or Medical Details *

Transportation Authorization- (check off to authorize) *

I authorize the Beaver Bus Lines to transport my child to and from camp for Anish Healing Centre's Language Adventures Summer Day Camp

I authorize my child to utilize a canoe, kayak or dragonboat *a life jacket will be supplied and MUST be worn

I do not authorize Beaver Bus Transport as I will be transporting my child to and from camps

Required

Photography, Filming and Recording-

We will have staff present who will be taking photos for our website and social media platforms. By attending Anish Healing Centre's Language Anventure's Camp, you consent to photography, audio, and video recording. Your presence allows for the use of these materials for promotional purposes, while releasing the Foundation and its affiliates from any liability. You waive rights to claims for payment or royalties and for review or approval of the materials. You acknowledge being fully informed of this consent and waiver before entering the event.

I Acknowledge that I have read and consent to photography, audio, and video recording.

Consent *

I am the legal guardian for the above named child who is under the age of 18

Required

I (legal guardian) will be attending camp with my child *

I will be attending

I will not be attending camp with my child

Required

Legal Guardian/s Phone Number *

Legal Guardian's Signature *

Date *

YYYY

Your SUPPORT allows us to continue programs like this!

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