Jamie Leduc (204) 290-­‐4003 [email protected] http://www.eyeconic.ca/ CAMPER INFORMATION: Participant’s Name: Given Names
Date of Birth: / / Surname
month day year
Male ! Female !
Address:
City:
Province:
Postal Code:
Home Phone: ( )
Cell: ( )
Email:
EMERGENCY CONTACT INFORMATION: Parent/Guardian: Name:
Phone (Home):
Work:
Cell:
Work:
Cell:
Name:
Phone (Home):
Name:
Phone (Home):
Work:
Cell:
Other Emergency Contact (family, friend, etc.): My child is authorized to leave Summer Camp: ! with the above-­‐named people; and/or ! on his/her own. Custody Restrictions: ! with the above-­‐named people; and/or ! on his/her own. ! No ! Yes. If yes, please attach copy of court order and state restrictions below: ACTIVITY INFORMATION (check the one or two that apply): Dates
! Animation Workshop (Teens)
! Youth Multi-­‐Media (ages 9 -­‐12)
! Game Design Workshop (Teens)
! Movie Making Workshop (Teens)
! Teacher PD Animation & Game
! Teacher PD Movie & Multi-­‐Media
July 5 – 8, 2016, 9 am – 3:00 am, Monday to Friday July 12 – 15, 2016, 9 am – 3:00 am, Monday to Friday July 5 – 8, 2016, 9 am – 3:00 am, Monday to Friday July 12 – 15, 2016, 9 am – 3:00 am, Monday to Friday Cost
$300
$280
$300
$300
July 5 – 8, 2016, 9 am – 3:00 am, Monday to Friday $300 July 12 – 15, 2016, 9 am – 3:00 am, Monday to Friday $300 DAY CAMP REGISTRATION FORM JULY 2016 Manitoba Health Care #:
Family Doctor:
Allergies:
Doctor’s Phone #:
Immunizations up to date? yes no
Medication:
MEDICAL INFORMATION: Medical Issues and Special Considerations: (Please be specific.) GENERAL PERMISSION / AGREEMENTS / CONSENT: Permissions / Privacy: 1. In case of accident or illness, if a parent or guardian cannot be reached, Summer Camp facilitator will take your child to the emergency ward of the nearest hospital. Signing this consent form gives your authorization to the College to seek emergency health services for your child when needed. 2. Information collected on this application will be used by the College and Eyeconic Educational Technology Services for registration, communication and medical purposes only on a “need to know” basis and is collected under the authority of The Freedom of Information and Protection of Privacy Act and The Personal Health Information Act. Agreements: 1. Discipline is handled using a 3-­‐strike system. If a camper misbehaves or acts in an unsafe or inappropriate manner (first strike), he or she will receive a warning. If the behavior continues (second strike), a phone call is made to the parent(s)/guardian(s). If the behavior continues after the call (third strike), the camper is sent home. Summer Camp has a violence-­‐free policy to ensure the safety of all our participants. Any physical misconduct will result in the immediate removal from the program. Summer Camp reserves the right to refuse access to camps or programs to any participant for inappropriate behavior. 2. By signing this consent, I agree to allow Summer Camp, Eyeconic Educational Technology Services to reproduce the likeness of my child (photo, video, etc.) for use in promotional materials or publications. 3. Mid-­‐Ocean School of Media Arts computer access is designed for educational purposes only. Summer Camp has taken precautions to restrict access to all controversial materials and I, the undersigned, will not hold Summer Camp responsible or Eyeconic Educational Technology Services responsible for material acquired from the network. 4. Cancellation and full registration refund can be made any time prior to June 22, 2016 by email to [email protected]. No refunds will be considered after that date. Consent: I, the undersigned, the Parent/Guardian of the aforementioned camper, consent to his/her participation in the Summer Camp summer program and related activities. The information in this application is correct and I am the legal parent or guardian of (child’s name). I hereby have read and agree to all terms and conditions as stated on both pages of this registration form. I have submitted my full registration payment. Signature of Parent/Guardian Date Printed name of Parent/Guardian REGISTRATION: In order to complete your full registration of the Summer Camp, you must fill out this form and included the full registration payment. Registrations are non-­‐refundable after June 22, 2016. Registrations are accepted online at http://www.eyeconic.ca/. WE LOOK FORWARD TO SEEING YOU AT CAMP! A camper package detailing where to come for camp, what to bring, etc., will be mailed or emailed approximately two weeks before the camp start date.