FAMILY INFORMATION
Campers First Name(required):
Campers Last Name(required):
MaleFemale
Address(required):
City(required):
Postal Code(required):
Email Address(for camp info):
Grade (required):
School(required):
Date of Birth(required):
Home Phone Number:
Parent's Name(required):
Work #:
Cell #(required):
2nd Parent's Name:
Cell #:
Parent's Marital Status(required):
—Please choose an option—SingleMarriedDivorcedWidowedRe-Married
If divorced/separated, camper lives with:
Parent 1(name):
Parent 2(name):
Name of step parents if re-married:
Are there any restrictions on either parents access/custody?
YesNoN/A
If yes, please email a note with details.
CAMP DATES AND FEES
Please indicate the day(s) you are registering for:
Dec 22Dec 23Dec 24Dec 26Dec 29Dec 30Dec 31Jan 2Jan 5
All 9 days : 495$ 8 days : 450$ 4 days : 230$ Daily : 60$ Total cost (please enter the total cost based on the number of days you are registering for :
Name of 1 Friend for your child to be grouped with (Friend must be the same age between Oct 1-Sept 30):
We will be happy to help you organize babysitting with our staff at an additional fee. Extended day fees are only paid on the first day of camp. Please indicate the days needed.
All 9 DaysDec 22Dec 23Dec 24Dec 26Dec 29Dec 30Dec 31Jan 2Jan 5
Please indicate the times needed (7:30-9:00 am and 4:00-5:30 pm)
Name(other than parent)(required):
Phone Number(required):
Relationship to camper(required):
Camper Medicare Number(required):
Expiry Date(required):
Pediatrician Name(required):
Phone #(required):
Allergies:
Other Medical Info (please include any delays, autism or other):
THIS FORM FULLY DISCLOSES ALL MEDICAL CONDITIONS THAT MIGHT ARISE OR NEED ATTENTION DURING THE CAMP SEASON. THE CAMP CANNOT ACCEPT RESPONSIBLITY FOR PREVIOUSLY KNOWN MEDICAL CONDITIONS THAT ARE NOT DISCLOSED ON THIS FORM.
I hereby authorize the Day Camp to take all necessary steps concerning my Child’s health in case of emergency.
In lieu of a signature, please check this box to agree all statements are true: I agree
Date(required):
We realize that there are a lot of colds and viruses going around. If your child is feeling unwell, please keep them home. Children should not be at camp unless they are fever free (without the help of meds) for 24 hours. They should not be at camp if they have vomited or had diarrhea in the past 24 hours If they are slightly coughing from a leftover cold, please test them prior to sending them to camp. We encourage mask wearing for children who may still be coughing from a past cold. Parents must discuss with their child proper hygiene etiquette (frequent/proper handwashing, coughing / sneezing into elbows, and refraining from touching their face, eyes & mouth).
Reminder that parents should not be rude or disrespectful to any staff or counselors at camp. If you have an issue that needs to be resolved, please contact one of the camp directors directly. Remember, our youth staff are still learning and while emotions may run high, it’s best to speak with someone who has more experience. Children who cannot respect the staff and fellow campers could be expelled from camp. Please remind your child about not getting physical when upset, using fowl language, and treating every camper in their bunk with kindness. We are all there to have fun!
In lieu of a signature, please check this box to agree all statements are true:I agree
RELEASE FORM/WAIVER
Parents agree to release and indemnify, Camp Khaos Day Camp, owner, director and all staff from any and all claims for damages arising as a result of any accident, injury, illness or otherwise, sustained by the herein named child arising from participation in any camp activities, wherever they may be, either on or off property.
Child Name(required):
Parents name(required):
LANGUAGE OF CONTRACT
All Parties agree that the language of this contract is in English.
Toutes les personnes acceptent que la langue de ce contract soit en anglais.
REFUND & NSF AGREEMENT
The refund policy is as follows: Fees will not be refunded after the start of the program. Refunds before this time will be subject to a cancellation fee of 30%. If the camp is unable to accept your child, all monies will be refunded. There will be a $25.00 charge for all NSF cheques regardless of the reason.
Important Note: If a child is ill or sick and unable to attend a camp date for whatever reason, unfortunately there are no refunds or credits possible. Please understand that a spot is held, and costs are still assumed whether your child is there or not. Thank you for understanding.
I hereby certify that I have read and understand the refund & NSF agreement and agree to the provisions of this agreement.
PHOTOGRAPH RELEASE
The undersigned agrees to grant permission for use of the child’s photograph in printed and electronic media in connection to the Camp Khaos Day Camp.
I hereby certify that I have read and understand the Photograph release, and agree to the provisions of this agreement.
In lieu of a signature, please check this box to agree all statements are true:I agreeI disagree
PAYMENT
Please send payment Via etransfer to campkhaos@yahoo.com. Use your child’s first name as the password. Once space is indicated as available by Camp Khaos, it will be held only for 48 hours. Your spot is only confirmed once payment is made in FULL and accepted by the camp.
I agree
If you prefer to pay by cheque: MAKE ALL CHEQUES PAYABLE TO: Viki Zerdok Drop off in mailbox at: 168 Sommerhill, DDO, Quebec, H9A 1X1
Returning campers do not need to fill out the below unless the info has changed.
Legal Name (person claiming childcare credit): SIN (required by the government in order to get an official tax receipt): Upon submission , please check your email for an auto reply confirmation. If you do not see it, please check your spam/junk folder.
