Cyo.on.ca

DAY CAMP REGISTRATION FORM 2012
General Information
Camper Details
First Name: _________________________________ Last Name: _________________________________
Address: _________________________________________________________________________________
City: ______________________________________ Postal Code: ___________________
Home Phone: (_______) ________- _____________ Age: (at camp time): __________
Email: _____________________________________ Date of Birth: month / day / year
School: ____________________________________  Male  Female
Parish/Church: ______________________________ Shirt Size (s, m, l or xl): Youth _____ or Adult _____ (your registration includes a Camp Brebeuf T-Shirt)
Session Requested (check all that apply):
 Session 1
Around the World in 5 Days
 Session 2
Christmas in July
 Session 3
Land Before Time (Dinosaurs) Monday, July 30-Friday, August 3, 2012
 Session 4
Battle of the Bands
 Session 5
Sports Extravaganza
Monday, August 13-Friday August 17, 2012 Fees
Per Session = $145.00 (We require full payment per week for Day Camp)
Fees due with registration
Cancellation Policy: A $40.00 cancellation fee will be charged if a session is cancelled at least 21 days in advance. A
$100.00 cancellation fee will apply if cancelled fewer than 21 days prior to the session.

Method of Payment
 Cheque/Money Order for $____________ enclosed.  Charge $ ______________  Visa or  Mastercard

Card Number: ________________________________ Expiry Date: month / day / year
Cardholder Name: _____________________________ Cardholder Signature: __________________________

Special group request
We will make every effort to place campers in the same group as requested below, provided:
a) parents of all the campers make the same request
b) campers are of approximately the same age.
We will honour two requests.
 I would my child placed in the same group with the following campers:
Name: _________________________ Age: ___
Name: _________________________ Age: ___ FOR OFFICE USE: Date Received: __________________ Deposit: ________________
DAY CAMP REGISTRATION FORM 2012
Declaration of Consent
Session # ______________
I (print name) __________________________________________ as the legal parent or guardian of (print child’s name) ________________________________________ in applying for registration for my child to C.Y.O. Camp Brébeuf hereby;  Give consent for my child to participate in all aspects of the camp program.  Understand that the Camp Director reserves the right to terminate the stay of any camper when it is deemed to be in the best interest of the child or the camp. In such cases proportional refund will be made.  Release and indemnify Camp Brébeuf and the Catholic Youth Organization of the Diocese of Hamilton from any and all claims for losses or articles and damages arising as a result of any accident, injury or otherwise sustained by the child named above during participation in the camp  Permit the use of the likeness of my child (in photographs, video etc) in promotional material by Camp Brébeuf and the C.Y. O. of the Hamilton Diocese.  Agree to the collection, use and storage of the information contained in this registration form as per the Privacy Policy of the Catholic Youth Organization. Copies of the policy are available at http://www.cyo.on.ca/privacy-policy.php. The information is gathered for the purposes of registration, processing payment and ensuring camper health and wellbeing during the program. Parent/Guardian Name (please print): ___________________________________________________ Parent/Guardian Signature: ___________________________________________________________ Date: _____________________________________
The following people are authorized to pick up my child from Camp Brébeuf:
Name: _____________________________________ Relationship to child: ____________________________
Name: _____________________________________ Relationship to child: ____________________________
Name: _____________________________________ Relationship to child: ____________________________
Return payment and registration form to:
Questions about registration or camp?
N0B 2K0
Fax (519) 856-2560
On receipt of this registration and deposit a Confirmation Package will be sent to you.
How would you like to receive this confirmation package. Email  Mail 
DAY CAMP REGISTRATION FORM 2012
Medical Information Form
Session # ______________
Camper Details
First Name: _____________________________ Ontario Health Card #: ______________________________ Exact Name on Card: ________________________________ Name of Family Doctor: _______________________ Telephone: If the camper does not posses an OHIP card a copy of their medical insurance must be attached
Emergency Contacts
1. Parent/Guardian: _______________________________
2. Emergency Contact*: ____________________________ 3. Emergency Contact*: _____________________________ *These people know my child and have agreed to be contacted in the event I am not available
Immunizations (Please check & date)
 Pertussis month / day / year
 MMR (Measles, Mumps, Rubella) month / day / year  TDP (Tetanus, Diptheria, Polio) month / day / year
History of Communicable Diseases (If camper has had or has any of the following, please check)
 Chicken Pox

Other Health Issues: (If camper has had or has any of the following, please check)
 Sleep Walking
 Other: ______________________________  Other: ______________________________ If not, has she been told about menstruation? Yes  No 
Health Declaration and Emergency Authorization
To the best of my knowledge, this camper is in good health, does not have a communicable disease and is able to
participate in all aspects of the camp program. If he/she becomes exposed to any infectious disease four weeks prior to camp, I understand that the Camp Director must be notified in writing. I give permission for the medical information provided to be shared with the appropriate camp staff and outside medical personnel as necessary. Authorization for Emergency Medical Treatment
In case of an emergency and we are not immediately available for consultation, I hereby give permission to the physician
selected by the Camp Director, to hospitalize, secure proper treatment for and order injections, anesthesia or surgery for
my child, as named above with the cost of necessary prescriptions and medical expenses to be borne by me. Name of Parent/Guardian (please print): ________________________________________________________ Signature of Parent/Guardian:_________________________________________ Date: ___________________ DAY CAMP REGISTRATION FORM 2012
Medical Information Form
Session # ______________
First Name: ____________________________ Weight: _______________ Height: __________
Medication
All medication, vitamins etc must be turned over to the Wellness Coordinator at registration. They should be
brought to camp appropriately labelled for each camper.
Please indicate if camper will bring his or her own  EPI Pen or  Inhaler.
Please list any medications your child will bring to camp (attach list if more space is needed):
Health Condition
Medication Name (e.g. Salbutamol,
/Treatment
Dosage & Form
Administer

Allergies
Please describe any allergies your child may have to the following (attach list if more space is needed):
Allergy
Exposure
Reaction
Treatment

Dietary Restrictions
 lactose-intolerant
 vegetarian: (e.g. lacto-ovo, vegan, no red meat) _________________________  other (please describe) _____________________________________________
Other Relevant Information
Please describe other relevant medical information including health conditions not treated with medication,
recent operations, illness or injuries this camper has had and give details:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Source: http://www.cyo.on.ca/brebeuf/registration/2012DayCamp.pdf