Summer Camp Registration Form
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1
2A sport, fitness and life skills
facility for people of all abilities.
varietyvillage.ca
Summer Camp Registration
CONTACT INFORMATION
First Name ________________________________________ Last Name _______________________________________________
Address __________________________________________________________________________________ Apt # ___________
City ___________________________________________________ Prov. _____________ Postal Code _____________________
Phone ___________________________ Bus. Phone ____________________________ Cell ______________________________
Email Address ______________________________________________________________________________________________
Date of Birth (mm/dd/yy) __________ / ___________ / ___________ Male Female
Health Card No. ____________________________________________ Membership No. __________________________________
Emergency Contact ________________________________________________ Relationship ______________________________
Phone ___________________________ Bus. Phone ____________________________ Cell ______________________________
MEDICAL INFORMATION
DISABILITY? Yes No If yes, please specify: ________________________________________________________________
Are there any concerns (physical/social etc.) of which we should be aware in order that we may assist in your camper's adjustment
in the camp? Yes No
If yes, please specify: _________________________________________________________________________________________
ALLERGIES? (food, drug, other) _________________________________________________________________________________
MEDICATION? Yes No If yes, please specify ________________________________________________________________
Permission to be administered during camp? Yes No Time/Dose: _______________________________________________
Please Note: To ensure that all campers actively participate in and enjoy or
camps, youngsters in any of the following groups must be accompanied by an
OFFICE USE ONLY
attendant, support person, or caregiver provided by the family or organization:
Medically Fragile ‐ g‐tubes, tracheotomy‐tubes, requiring suctioning
Physically unable to feed, transfer, and/or perform personal hygiene
Date received
Unable to participate in group activities because of behavioral problems
Physically or verbally aggressive.
_________________________________
Parent/guardian will be contacted for possible registration withdrawal if it is
Verified by
deemed that the youngster/caregiver arrangement is not working to the benefit,
_________________________________
enjoyment or safety of the camper.
We would be pleased to discuss your questions or concerns and we hope that
everyone can get involved for another exciting year of Camp programs.
Variety Village 3701 Danforth Avenue Scarborough ON M1N 2G2 416‐699‐7167 1‐800‐387‐7686 FAX 416‐699‐3926 varietyvillage.ca
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Parent category: Life