GO Camp Registration Form Youth Information Youth Information Name of Youth Attending GO Birthdate Grade Health Card Number Allergies or health concerns - please note if severe T-Shirt Size: Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult X-Large Parent/Guardian Contact Information Name(s) of Parent/Guardian: Address Apt/Unit # PO Box City Postal Code Cell Number Home Phone Email Address Do you prefer to receive updates/reminders via email or phone?EmailCell PhoneHome Phone Emergency Contact Information Emergency Contact Name Emergency Phone Number Relationship to Child Additional Information Is your child at any point going to be walking home from Camp?YesNo Will someone other than the parent/guardian on this form be picking up your child? Please list all names that apply: Consent (Please check the box beside each category that you are giving consent to.) I/We authorize the administration of any first aid treatment necessary, and in the case of medical emergency, give permission to the Physician selected by the supervisors to hospitalize and secure proper treatment for my child as named above. Every effort will be made to contact parents or guardians before such action. I/We acknowledge that it is my responsibility to take the necessary steps for insuring against personal injury, property damage, or any loss by my child or by self. I also acknowledge that I must assume total responsibility for ALL medical coverage, accidental insurance and personal injury, or any other loss or damage. I will also pay for the cost to have my child sent home if he/she is unwilling to comply with the rules. I/We agree to permit reasonable use of photos, videos, written materials or other pictures of applicant student in promoting KYFC and their activities and programs. We understand that these could appear in agency newsletters, brochures, website or social media; or in local newspapers, on television, and might identify participants by first name. We wish to inform you of this in advance in order to avoid any surprises or misunderstandings. There are other great programs being offered in our community that are run by other organizations and churches! Would you be interested in receiving information about other programs? This would require Youth Unlimited to pass on your contact information. YES please pass on my contact info for programs that are suitable for my childNO I am not interested at this time By checking this box I give permission for the above youth(s) in my care to participate in the event(s) set forth by Kawartha Youth for Christ/ Kawartha Lakes Youth Unlimited and any of its subsidiary programs. Furthermore, I do not hold Kawartha Youth for Christ/ Kawartha Lakes Youth Unlimited or any of its subsidiary programs responsible for any harm that may occur to the above youth(s)) as a result of his/her willful participation in the event(s). Please Note: Subsides available, please contact Rebecca Sage directly to inquire. Payments may be made by cash, cheque or E-transfer. Please arrange to give cash or cheques to Rebecca Sage. Cheques should be made out to 'Youth Unlimited". If you wish to pay by E-transfer please send it to email@example.com with a note that it is for "Summer Camp Registration - Bobcaygeon." For more information please contact Rebecca Sage at firstname.lastname@example.org or 705-868-6898.