Planet Kids Summer Camp
July/August 2015
July 6 ‐ 10 July 20 ‐ 24 August 3 ‐ 8 August 17 ‐ 21 Child Information: Last Name:
First Name:
Middle Name/Initial:
Birthdate (M/D/YYYY): Street Address:
City, Province:
Age: Postal Code:
BC Care Card Number: Allergies or Medical Conditions we need to be aware of: In the case of an emergency, I give permission for NEAT to call upon the local hospital or ambulance to treat my child, _______________________________. Name:___________________________________ Parent/Guardian #1 Information: Name: Relationship to Child: Email: Home Address (If different from above ):
Home Phone:
Cell Phone:
Employer:
Work Phone:
Best way to reach you: Cell Work Home
Parent/Guardian #2 Information: Name: Relationship to Child:
Email:
Home Address (If different from above ):
Home Phone:
Cell Phone:
Employer:
Work Phone:
Best way to reach you: Cell Work Home
General Information/Waiver: Emergency Contacts (other than parents/guardians):
Contact Number:
Persons Authorized to Pick Child/ren Up: Are promotional photos ok? Yes No I give permission for my child, __________________________________, to leave the facility under the supervision of NEAT & North Peace Cultural Centre employees to participate in Plant Kids Summer Camp activities. Yes No
Parent Signature: __________________________________________ Date:____________________________
OFFICE USE ONLY: PAID:
DATE: _________________________ AMOUNT:_$__________________ CASH
CHEQUE (#__________)
DEBIT/CREDIT