Name:

Gender: Male Female

Address:

City:

Postal Code:

Date of Birth:

Grade as of September 1, 2008:

School:

Emergency Contact Information:

Name:

Relationship:

Home Phone:

Work Phone:

Email:

Alternate Emergency Contact Information:

Name:

Relationship:

Home Phone:

Work Phone:

Email:

Medical Information:

OHIP Number:

Do you have any existing medical conditions or special needs which would affect your ability to participate?:

Yes No

Please Note that due to our safety obligations, campers with special needs requiring one-on-one attention will be expected to have an additional support person present at the camp.

If yes, please explain:

Do you have any allergies?:

Yes No

If yes, please explain:

**IMPORTANT:
In order for your child to participate, you must fill out a Waiver of Liability and Indemnity and fax it to the Skills Canada - Ontario office at 519.749.6322.

**Skills Canada - Ontario staff cannot administer daily medication to participants; all daily medications must be self-administered.

Agreement to Participate/Be Photographed Waiver

I understand that off-site field trips are part of the camp agenda. I hereby give my son/daughter permission to participate in all sanctioned events. I grant permission for my son/daughter to be bussed to off-site locations. I also give Skills Canada - Ontario consent to take pictures of my son/daughter/charge for future promotion of this event. I also agree to the use of photographs by any media group. I am aware that my child will benefit from the use of both fine and gross motor skills to participate in this camp program. I have read and understand the rules and conditions of participation as set out on this form and I agree to them.

Agree Disagree

Privacy Statement

Skills Canada - Ontario respects your privacy. We protect your personal information and adhere to all legislative requirements with respect to protecting privacy. We do not rent, sell or trade our mailing lists. The information you provide will be used to deliver services and to keep you informed and up to date on the activities of Skills Canada - Ontario, including programs, services, special events, funding needs, opportunities to volunteer or to give, open houses and more through periodic contacts. If at any time you wish to be removed from any of these contacts simply e-mail gails@skillscanada.com and we will gladly accommodate your request.

Fee $150

The cost of attending the camp is $150 per camper. Skills Canada - Ontario accepts Visa and cheques. (Please make cheques payable to Skills Canada - Ontario.)

I would like to pay with a credit card. (A Skills Canada - Ontario representative will contact you concerning payment.)

Payment Comments:

Questions?

Please contact Karen Throupe, "Skills Work®” Camps Coordinator, Skills Canada - Ontario, 1.807.684.8853 or email karent@skillscanada.com.