Summer Camp Registration

General Information

Camper's Name*

First Last

Parent's Names:

Father's Name*

Prefix First Last

Mother's Name*

Prefix First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address must match credit card billing address.

Camper's address is same as billing address*

Yes
No

Camper's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Tel:*

Father's Cell Phone*

Father's Email*

Father's Place of Work*

Father's Work Address*

Mother's Cell Phone*

Mother's Email*

Mother's Place of Work*

Mother's Work Address*

Camper Profile

Name*

First Last

Birth Date*

Present Age*

Please enter a number from 0 to 30.

Name of School Camper is Attending*

Grade

Describe support currently receiving at school*

1:1
small group settings
not applicable
Other - please describe

Please describe here

Emergency Contact

Name (other than parent or guardian)*

First Last

Phone*

Relationship to Camper*

Medical Information

Immunization Records*

Will be uploaded below
Will be sent in to the office ASAP

Upload immunization records

Must be in jpg or pdf format

Doctor's Name*

Doctor's Phone Number*

Doctor's Full Address*

Diagnosis*

Please list all diagnosis

Medical Concerns

Please list any medical condition or special circumstances that our staff should be aware of to assist us in the care of your child. The following are examples: recent surgery, frequent infections and colds, headaches, stomach aches, diarrhea, constipation, vomiting, bedwetting, sensitivity to insect bites, insomnia, anxiety reactions, emotional outbursts, gastrointestinal bleeding, biting, drooling, wounds, special equipment. If your suggested treatment for those concerns is an over the counter medication, please send along a prescription for it.

Medical Concern	Suggested Treatment

Ambulatory

Camper is Ambulatory
Camper Utilizes Stroller
Camper Utilizes Walker
Camper Utilizes Wheelchair

Does your child have a specific neurological condition other than seizures?

Yes
No

Please Specify

Does your child have a seizure disorder*

Yes
No

How long does a typical seizure last?*

How frequent are the seizures?*

Please describe the typical manifestation of the seizure:*

(For example: precipitants, colour change, aura, hallucinations, tremors, loss of consciousness, generalized or localized seizure activity, loss of posture, or other physical or behavioural manifestations)

Exact seizure protocol in the event your child has a seizure?*

(Please be extremely detailed in your description and specific in what steps should be taken)

Does your child receive Lorazepam (Ativan) or any other type of emergency seizure medication or intervention (as needed)*

Yes
No

Please notate exact dosage and when it is indicated:*

Is camper on medication to control seizures?*

Yes
No

Please specify medication*

Please list all prescribed and over the counter medications that your child is currently taking: (if your child is taking any medications, a separate form will be emailed to you. Please note that a copy of a prescription is required for any medication that will be administered in camp)*

Does your child have any allergies?*

Yes
No

Please list allergies and indicate sensitivities and/or anaphylactic status*

Allergy	Anaphylactic or Sensitivities

Is an Epi-Pen required?*

Yes
No

FEEDING INFORMATION

Does your child have any dietary restrictions?

Yes
No

Please specify*

Diet Consistency

Regular
Puree
Soft (easy to chew foods)

Liquid Consistency

Regular/thin
Nectar
Honey
Pudding

Feeding Skills

Self
Assistance Required

Please specify*

Does your child have a G-Tube?*

Yes
No

Please indicate the purpose of camper's G-Tube*

Supplemental Feeds
Full Nutrition
Medication only
Fluids only

If your child has a G-Tube you will be sent a separate form to fill out.

Please describe your child's level of independence with self care (eg. feeding and toileting)*

Describe your child's swim level*

My child needs to be held or wear a neck floater
My child is comfortable in water but can not swim
My child is in lessons and has completed level: (fill out level below)
My child has never been in a pool before

My child has completed this level in swim lessons*

Please list individual therapies your child is currently receiving on a regular basis.

Occupational Therapy
Physiotherapy
Speech and Language
Music Therapy
Behaviour Therapy (IBI)
Other

Individual Therapy Session:
We recognize the importance of continuing therapy sessions over the summer to avoid regression of acquired skills. While the camp program offers many group therapies, individual therapy sessions are available for a subsidized fee and are built into the camper's daily program.
Physiotherapy: $65
Occupational Therapy: $65
Speech Therapy: $75
Behaviour Therapy: $55

Individual Therapy Sessions: I am interested in discussing this option with the camp director

Yes
No

Does your child have any specific Dislikes/Fears that we should be aware of?*

Does your child have preferred items or activities that can potentially be used as reinforcement?*

Please describe your child's means of communication? (verbal, gestures, nonverbal- if so, how does your child get his/her needs met?)*

Behavioral Techniques that work (ie. timer, charts)*

Other good tips to know*

Upload picture

Must be in .jpg, .png or .pdf format

Payment Information

Program	July Session July 1 - 26	August Session July 29 - Aug 9	Overnight Aug 14 - August 20	Full Summer July 1 - Aug 20 (Daycamp+Overnight)
Junior Division (Includes Toddlers & Juniors)	$2,000	$1,000	$950 +$50 transportation fee	$4,000
Muscles N Motion	$2,500	$1,250	$1,150 +$50 transportation fee	$4,950
Older Division (Includes Active Adventures, Peers IN Play & Social Adventures)	$2,000	$1,000	$950 + $50 transportation fee	$4,000
Teen Program	$3,000	$1,500	$1,200 + $50 transportation fee	$5,750

New campers to overnight need to be approved first by the camp director. Priority will be given to returning overnight campers.

A deposit will be required to secure a spot for overnight camp. This deposit is refundable if the medical director does not clear the camper for any reason.

Camp 18 operates as a licensed daycare. York Region funding can be applied toward camp fees.

I receive York Region funding at KCC or another day care.

Payment Options*

I would like to pay in full online.
I would like to pay a deposit now and I would like the office to contact me to discuss payment plans.

Divisions:*

Junior Division: (includes toddler, juniors)
Muscles N Motion
Older Division (includes Active Adventures, Peers IN Play, Social Adventures)
Teen

Please check ONLY ONE of the above

Junior Division Month:*

July
August
Overnight
Full Summer

Muscles N Motion Month:*

July
August
Overnight
Full Summer

Older Division Month:*

July
August
Overnight
Full Summer

Teen Month:*

July
August
Overnight
Full Summer

Bussing Options

Depot Bussing to/from 15 Saranac Blvd for $25/week (includes morning and/or afternoon)
Door to Door Transportation for $10/way.

Depot Bussing

July - $100
August - $50

Transportation: **

I am interested in transportation for the July session mornings for $200.00.
I am interested in transportation for the July session afternoons for $200.00.
I am interested in transportation for the August session mornings for $100.00.
I am interested in transportation for the August session afternoons for $100.00.

**Bussing is available from Major Mac to Eglinton, and Avenue Road to Dufferin Street. If you are outside the route please contact us to see if it can be accommodated. Please note an additional fee may be incurred for addresses outside the route.

Pickup Address:

Drop Off Address:

Divisions*

Junior Division
Muscles N Motion
Older Division
Teen

Month*

July
August
Overnight
Full Summer

Month*

July
August
Overnight
Full Summer

Month*

July
August
Overnight
Full Summer

Month*

July
August
Overnight
Full Summer

Bussing options

Depot Bussing to/from 15 Saranac Blvd for $25/week (includes morning and/or afternoon)
Door to Door Transportation for $10/way.

Transportation

I am interested in transportation for the July session mornings for $200.
I am interested in transportation for the July session afternoons for $200.
I am interested in transportation for the August session mornings for $100.
I am interested in transportation for the August afternoons for $100.

Depot Bussing Payment

July
August

Pickup Address

Drop Off Address

Parents Please Note:

We do not operate our own bus line. As such we have little control over the transportation mishaps but we work tirelessly to avoid them. Please consider the following before signing up for bussing: 1. We cannot ensure that there will be a monitor on the bus for the entire route. The companies we use drive for TDSB and all drivers have proper background checks and licensing. If we have a staff on the bus for part of the route, her job is to update us on arrival times and of any delays and to help the campers off the bus as they arrive at camp. Please be prepared to put your child on the bus and take them off at drop off. 2. We cannot control busses coming late, last minute driver changes, campers delaying the route and missed stops. We have a dispatcher on the phone throughout the entire route and we do our best to keep on top of delays and let parents know as soon as possible. However, from previous years we know that there will be delays and we need everyone to be patient and understanding for the first few days for sure. 3. Our route begins at Elgin Mills/ Thornhill woods and continues along Bathurst St to camp. When there is enough demand we can arrange for a bus that starts at St Clair and covers the east end pickups. If you live far east and west and you are unsure if your address is included please contact us prior to signing up for the bus service.

Before and After Care

Before and After Care is available at camp. Before Care is from 8:15-9:15. After Care runs from 3:00-5:00. This is respite babysitting. There are no recreational programs running during this time. Please note the staff ratio is 1:4. If your child requires 1:1 supervision, please contact us to arrange. The cost is $10/hour

Morning care for July - $200
Morning care for August- $100
After care for July- $400
After care for August- $200
I would like to discuss this option for my child.

After Care

After Care Options

Before and After Care is available at camp. Before Care is from 8:15-9:15. After Care runs from 3:00-5:00. This is respite babysitting. There are no recreational programs running during this time. Please note the staff ratio is 1:4. If your child requires 1:1 supervision, please contact us to arrange. The cost is $10/hour

Morning care for July
Morning care for August
After care for July
After care for August
I would like to discuss this option for my child.

Total

$ 0.00 CAD

If you decide you only want to pay a partial amount or a deposit now, please go back up to the top of this section and choose a different payment option. You will have to check off your session and month again but your personal info will still be saved.

Conditions of Enrollment

1. Camp 18’s 2019 July session begins July 1st 2018 and ends on July 26th, 2019.
Camp 18’s 2019 August camp session begins Monday July 29th, and ends on August 9th.
2. Applications will not be processed unless accompanied by a $350 deposit per child and a signed application form. All deposit payments must be dated the date of registration. Cheques are payable to Kaylas Children Centre.
3. Campers will not be admitted to camp until the application is completed and the balance of fees are paid for the specific period.
5. While every reasonable effort is made to safeguard campers’ belonging while at camp, Camp 18 cannot be held responsible for the loss, damage or theft of any of the campers’ belongings and medical equipment/devices.
6. Seating, personal and mobility equipment, ie adaptive bikes, commodes, used by an individual camper are the responsibility of the parents to acquire (rent or bring).
7. Camp 18 cannot be held responsible for any and all claims for damages arising as a result of any accident, injury or otherwise sustained by the registered child(ren) arising from participation in any camp activities.
8. Parents agree to allow their child(ren) to participate in all camp activities, and in any supervised activities not on camp property.
9. Parents agree to give Camp 18 officials the authority to act on their behalf in case of emergency.
10. I/We have registered and submitted a $350 deposit (per child) and arranged post dated checks no later than May 1, 2019 or payment in full for the child(ren) that I/we am/are registering.
*Note: The deposit is nonrefundable for the session applied for, therefore a cancellation in any session will forfeit the deposit. 11. I/We hereby apply for registration for the herein named child(ren) for the camping services indicated in the application.

*

I agree to the terms and conditions listed above

Consent

I allow my child to use the bus to to travel off camp site, including to trips and swimming.

Pictures are how we tell parents the story of camp! Please choose your options for photo release below*

My child is photo released.
I would like to discuss this option with the camp director.

T-shirts*

First T-shirt is free. Each additional T-shirt is $15.00

Additional T-Shirts

Price: $ 15.00 CAD Quantity:

Payment

Total Camp Fees

This box shows you the full cost of the services you requested. You will have to pay a minimum deposit up front and the office will contact you for the rest. (This amount does not include additional therapy options)

Deposit Amount + Additional Payment

Please enter the amount of $350.00 in this field. If you would like to pay an amount above the mandatory deposit fees, add it to this amount.

Agreement*

I understand that the deposit is non-refundable.

Total Payment

$ 0.00 CAD

This total will reflect the amount you chose to pay as a deposit.

Billing Email*

Please enter the email you want to use for your billing address.

Credit Card

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Captcha

Untitled

First Choice
Second Choice
Third Choice

Name

This field is for validation purposes and should be left unchanged.