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Required fields are marked with asterisks (*)

Camper Intake Form

Please fill out this required form before your child’s first day of camp. One form per child. Only fill this form out once your child is registered for the camp program.

Any questions, please email summercamp@richmondhill.ca.

Camper Information

Add Another Week Remove Week

Camper First Name

Camper Last Name

Emergency Contacts

Emergency Contact Name #1

Emergency Contact Number #1

Emergency Contact Name #2

Emergency Contact Number #2

Emergency Contact Name #3

Emergency Contact Number #3

Authorized Pick-Ups

Please add information for anyone who would be allowed to pick up your child from camp, including yourself. If a person is NOT on this list, campers will not be released. All persons must show valid ID when picking up campers. Names in this document must match the ID shown.

Authorized Pick Up Name #1

Authorized Pick Up Number #1

Authorized Pick Up Name #2

Authorized Pick Up Number #2

Authorized Pick Up Name #3

Authorized Pick Up Number #3

16. Children ten (10) years of age or older may sign themselves in and out of the program, as long as the City has written consent each time a child is being released from the program without an adult or authorized caregiver present.

I give permission for my child(ren), as listed above, to sign themselves in and/or out of the program. My child(ren) know they cannot sign out of the program until the program ends

Yes

Effective Start Date

Effective End Date

Allergies and Medication

Does your child have any life-threatening allergies or medical conditions?

Yes

Any additional information you would like to provide to staff?

Parent/Guardian Name

Parent/Guardian Email

Signature (type name to sign)

Date

Information Collection Notice

Personal information on this form is collected under the authority of the Municipal Act 2001, S.O. 2001, C.25, and will be used for the purpose of program registration and administration. Inquiries regarding this collection should be directed to the Office of the Clerk at 905-771-8800.

City of Richmond Hill