Planet Kids Summer Camp July/August 2015

DEBIT/CREDIT  

DATE: _________________________  AMOUNT:_$__________________OFFICE USE ONLY:

PAID: CASH  CHEQUE (#__________) 

  July 6 ‐ 10     July 20 ‐ 24    August 3 ‐ 8    August 17 ‐ 21  

Parent Signature: __________________________________________  Date:____________________________ 

Are promotional photos ok?                                                 Yes           No  

Emergency Contacts (other than parents/guardians): Contact Number:

Persons Authorized to Pick Child/ren Up:

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   

Name: Relationship to Child: Email:

Home Address (If different from above ): Home Phone: Cell Phone:

Employer:

Parent/Guardian #2 Information:

Work Phone: Best way to reach you:                  

Cell Work     Home General Information/Waiver:

Home Address (If different from above ): Home Phone: Cell Phone:

Employer: Work Phone: Best way to reach you:                  

Cell Work     Home 

Street Address: City, Province: Postal Code:

Parent/Guardian #1 Information:

Name: Relationship to Child: Email:

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:___________________________________

Child Information:

Last Name: First Name: Middle Name/Initial:

Birthdate (M/D/YYYY): Age: