Childrens_Summer_Camp_2023 - Town of Smiths Falls

Required fields are marked with asterisks (*)

Summer Day Camps 2023

Heritage House Museum

All programs require pre-registration with full payment in advance. Program size is limited so early registration is recommended.

Cost $150.00 per week / $35 per day

Child or Children's Names:

Health Card number(s):

Enter their Date of Birth(s), Age(s), and Grade(s):

Do they have any allergies, concerns, medication, or special needs?

Can they have outside food sources (candy, freezies, etc.) provided by staff?

Yes

Parent/Guardian Name:

Email:

Address

Phone Number(s):

Family Doctor Name:

Family Doctor Phone Number:

Emergency Contact Name:

Emergency Contact Relationship to Child(Children):

Emergency Contact Phone Number:

Choose which weeks / days you are booking for:

Week 1 July 17 - 21 Full Week ($150)

Monday July 17 ($35)

Tuesday July 18 ($35)

Wednesday July 19 ($35)

Thursday July 20 ($35)

Friday July 21 ($35)

Total Payment $:

To complete registration choose one of the following:

Visit us at Heritage House Museum to pay with cash, cheque, credit, or interac
Mail form with cheque to: Heritage House Museum, 11 Old SlysRoad, P.O. Box. 695, Smiths Falls, ON, K7A 4T6

Type of Payment:

Cash

Cheque

Visa, Mastercard or Debit

Parent/Guardian Consent

I have provided all of the health, behavioural and physical needs information which pertains to my child that is necessary for the leadership of this program to provide a safe experience for my child and other participants.

I understand that the program leaders will use their best judgment for maintaining a safe environment for each child. This may include refusing my child the privilege of participating in a portion of the program if they are behaving in an unacceptable manner.

I understand that the Smiths Falls Heritage House Museum will follow all guidelines published by the Ministry of Health.

I understand it is up to my own discretion on sending my child to the Heritage House Museum Day Camps.

I hereby give my permission:

To administer medication provided by me in accordance with proper and complete instructions that I will provide.

To exclude my child from the program if they fail the COVID-19 screening or begin showing symptoms.

To administer first aid if necessary.

To take my child off museum property for pre-arranged activities. (Splash Pad etc.)

To photograph/film my child while participating in a museum program, for promotional purposes.

To all local newspapers to print photos/articles related to my child.

To allow the Heritage House Museum to put photos on their website/Facebook page.

Parent/Guardian Signature

Clear

Date of signature:

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