Arts & Crafts Day Camp – Youth Day

Campers First Name: *

Campers Last Name: *

Parent/Guardian Name: *

Parent/Guardian Last Name: *

Parent/Guardian Email: *

Age of Camper: *

Parent/Guardian Phone Number: *

Parent/Guardian Phone Number 2:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Emergency Contact's relation to camper: *

Will camper be picked up by someone who is NOT their Parent/Guardian or Emergency Contact: * YesNo

If yes, please specify:

Health Card Number: *

Does your participant have any allergies/medical conditions? If none, enter 'None'. If yes, please list.: *

Does your child require any medication that the program instructor will have to administer/store? If no, enter 'No'. If yes, please indicate how.: *

I hereby authorize staff to perform any first-aid services deemed necessary for the health and safety of my participant.: * By clicking here I give my consent to the above statementBy clicking here I do not give my consent to the above statement.

I hereby authorize photographs taken of my child during the camps to be released to the MVBT website and other advertising sources. (Chronicle Herald, etc): * By clicking here I give my consent to the above statementBy clicking here I do not give my consent to the above statement.

I hereby authorize staff to walk my participant from the Musquodoboit Valley Bicentennial Theatre to Cornerstone Park, The Thoughtful Food Project Community Garden, and/or The Valley View Villa.: * By clicking here I give my consent to the above statementBy clicking here I do not give my consent to the above statement.

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