winter camo

WINTER CAMP REGISTRATION 2022 / 23

    FAMILY INFORMATION

    Campers First Name(required): Campers Last Name(required):
    MaleFemale
    Address(required): City(required):
    Postal Code(required): Email Address(for camp info):
    Date of Birth(required): School and grade(required):
    Home Phone Number:
    Parent's Name(required):
    Work #: Cell #(required):
    2nd Parent's Name:
    Work #: Cell #:
    Parent's Marital Status(required):
    If divorced/separated, camper lives with:
    Parent 1(name): Parent 2(name):
    Name of step parents if re-married:
    Parent 1(name): Parent 2(name):
    Are there any restrictions on either parents access/custody?
    If yes, please email a note with details.

    CAMP DATES

    Please indicate the day(s) 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):

    EMERGENCY CONTACT INFORMATION (if any person above cannot be reached)

    Name(other than parent)(required): Phone Number(required):
    Relationship to camper(required):
    CAMPER MEDICAL INFORMATION

    Camper Medicare Number(required): Expiry Date(required):
    Pediatrician Name(required): Phone #(required):
    Allergies:
    Other Medical Info (please include any delays, autism or other):

    PARENT CERTIFICATION

    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):
    EXTENDED DAY SERVICES

    We will be happy to help you organize babysitting with our staff at an additional fee.
    Please indicate the days needed.

    Please indicate the times needed (7:30-9:00 am and 4:00-5:30 pm)

    RELEASE FORM/WAIVER

    In the context of the Covid-19 Pandemic, Camp Khaos has put measures into place to minimize the risk of contagion and spread of the virus. These various procedures, can be found in the information package and could change based on directives from Quebec’s Public Health. It is the responsibility of parents and campers to respect these measures.

    By signing below, the undersigned understands and accepts these measures and have discussed the importance of following these measures with their participating child. The undersigned also understands that Camp Khaos cannot guarantee a Covid-19 free environment and accepts that there will be a risk of contagion.
    Parents also 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, Covid 19 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):

    In lieu of a signature, please check this box to agree all statements are true:I agree

    Date(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.

    In lieu of a signature, please check this box to agree all statements are true:I agree

    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.

    In lieu of a signature, please check this box to agree all statements are true:I agree

    Date(required):

    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

    Date(required):

    PAYMENT

    Please send payment Via etransfer to campkhaos@yahoo.com. Use your child’s first name as the password. Space is not confirmed until payment is received in full and accepted by Camp Khaos.

    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.


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