Camp de jour

Child’s first name *

Specify the nation *

last name *

Specify if other nationality *

Gender *

Male Female Non-binary

Language(s) spoken *

Français Anglais Algonquin/anicinabe Cree

Autre(s) *

Age *

School year in September 2023* *

Date of birth (DD/MM/YYYY) *

First and last names of primary parent or guardian * *

Prénom

Nom

First and last names of secondary parent or guardian *

Prénom

Nom

Address *

Ligne 1

Ligne 2

Ville

État

Code postal

Pays

Telephone number *

Mobile/Office *

Email *

Address *

Ligne 1

Ligne 2

Ville

État

Code postal

Pays

Telephone number *

Mobile/Office *

Email *

Social Insurance Number *

Emergency contacts *

Prénom

Nom

Emergency number *

Relationship with the child *

Emergency contacts *

Prénom

Nom

Emergency number *

Relationship with the child *

Is the child allowed to leave alone? *

Yes No

First and last names *

Does your child have any allergies? *

Does your child suffer from asthma? *

Yes No

Does your child suffer from diabetes? *

Yes No

Is your child taking any medication? *

Yes No

List of drug(s) or special recommendations *

Does your child have a special condition we need to know about? *

Autism Behavioural disorders Oppositional defiant disorder

Water safety *

Your child can swim alone Your child swims with a life jacket

Does your child have a bicycle? *

Yes No

Please tell us about your child’s challenges/needs so we can offer them personalized support. *

I authorize VDNFC staff to administer one or more non-prescription (“over-the-counter”) medications to my child, if necessary. *

Yes No

I authorize the VDNFC to use photos of me and my child to promote its activities. *

Yes No

I authorize my child to use the VDNFC and Taxi 24’s transportation services during activities organized by the day camp. *

Yes No

I authorize VDNFC staff to ensure that all necessary care is administered to my child in the event of an accident. I also authorize VDNFC staff to transport my child by ambulance and to admit my child to a medical facility. *

Yes No

The Val-d’Or Native Friendship Centre cannot be held responsible for loss, theft or accidents. Having read all the above information, I authorize my child to attend the day camp organized by the VDNFC. *

I agree

Action jeunesse

Day Camp Registration Form

Identification of Parents or Guardians

Persons other than the child’s parents or guardians who is authorized to pick up the child:

Authorizations