Child Information and Consent

Child's Name *

First

Last

Child's Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Parent/Guardian Name *

First

Last

Parent/Guardian Phone *

Parent/Guardian Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Parent/Guardian Email *

Parent/Guardian 2 Name

First

Last

Parent/Guardian 2 Phone

Parent/Guardian 2 Address

Address Line 1

Address Line 2

City

Province

Postal Code

Parent/Guardian 2 Email

EMERGENCY contact Name *

First

Last

Phone *

Additional People who may pick up your child (with phone numbers). ID will be requested *

Who will pick up your child within 30 minutes if they are ill (Parent/Guardian or Emergency Contact) *

Child's Health Card Number *

Please list any relevant health conditions or allergies, in detail. Include any/all medications. Please note medications must be discussed in person with staff.

Consent to Emergency First Aid and Transportation: I hereby give permission that my child listed above may be given emergency treatment by a staff member from this program if deemed necessary. I also give permission for my child to be transported by car or ambulance to an emergency center for treatment, and agree to hold this program and its employees harmless. Any costs associated to medical care and treatment will be the responsibility of the parent/guardian. *

I AGREE

Field Trips: I hereby give consent for my child to go on supervised field trips in the neighborhood (parks, spray pad, trail walks, etc.). *

I AGREE

Parent Agreement/Understanding: I agree to all of the FOLLOWING: (check all) *

Signature *

Clear Signature