2021 Registration Please choose the camps you would like to register your child in Summer Camp - Boys & Girls 8 - 12 yrs ($225/week)* Week 1: July 5th - 9th Summer Camp - Boys & Girls 8 - 12 yrs ($225/week)* Price: Week 1: July 5th - 9thSummer Camp - Boys & Girls 8 - 12 yrs ($225/week)* Price: Week 2: July 12th - 16thSummer Camp - Boys & Girls 8 - 12 yrs ($225/week)* Price: Week 3: July 19th - 23rdSummer Camp - Boys & Girls 8 - 12 yrs ($225/week)* Price: Week 4: July 26th - 30thTotal $ 0.00 CAD Child's Name* First Last What school does your child attend* Gender* Male Female Age at time of Camp*Birthdate* DD slash MM slash YYYY Where did you hear about Big Ben’s Camp?* Parent / Guardian InformationParent / Guardian Name* First Last Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone - Cell*Phone - Work*Would you like to list another Parent / Guardian Yes (Recommended) No Parent / GuardianParent / Guardian Name* First Last Email* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone - Cell*Phone - Work*Emergency ContactEmergency Contact Name* First Last Contact Number*Relation to Camper Does your child have any allergies?* Yes No Please Specify*AllergyReaction For multiple allergies please add more rows using the + iconDoes your child carry an EpiPen?* Yes No Does your child have any health conditions or take any medication that would impact their participation in Camp activities?* Yes No Condition*Medication Required?* Yes No Please Explain*Any other comments or items we should be aware ofChild’s Health Card Number* Expiry Date* DD slash MM slash YYYY MEDICAL TREATMENT AUTHORIZATION: I understand that, in the event my child requires medical or dental treatment while engaged in activities with the Camp, reasonable efforts will be made to contact a parent or guardian; however, if a parent or guardian cannot be reached, I hereby consent and give permission to the camp director or volunteer acting on behalf of the Camp as agent for me, to consent to any X-ray examination, injections, anesthesia, medical, dental or surgical diagnosis and treatment, and hospital care and treatment advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the law of Nova Scotia, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my children’s medical allergies, medications being taken, medical problems and other pertinent information. If there are any changes, I will notify the staff and/or director of the Camp. This MEDICAL TREATMENT AUTHORIZATION FORM is effective throughout the camp session for which my child is registered. I understand and agree to the above.* Yes No Please Type Signature to Agree* Date* CAMP CODE OF CONDUCT The environment at Big Ben’s camp is one that is inclusive and respectful of everyone participating. This includes Parents, Campers and Coaches. We encourage that each Camper comes with an excitement to participate, play and learn. If issues arise, we will work towards resolving them with respect and cooperation. If difficulties continue to persist, we will contact a parent/guardian in order to find an appropriate resolution. Camper Responsibilities: Be respectful and polite to all campers, coaches, and parents while at camp. Encourage other campers in a positive manner. Speak to your coach for assistance whenever needed. Big Ben’s Camp has a Zero tolerance policy for profanity, violent behavior, bullying, drugs or alcohol. Parent/Guardian Responsibilities: Adhere to the drop off, pick up procedure on a daily basis. Set a positive example for your child. Speak with the camp coordinator about any concerns or problems. Ensure that your child is behaving consistent with our Camp Code of Conduct. Failure to comply with the Camp Code of Conduct may result in your child being suspended and/or removed from the camp program. I understand and agree to the above.* Yes No Please type signature to agree* Date* WAIVER AND RELEASE OF LIABILITY FORM DISCLAIMER I AM AWARE of the possibility of health and safety risks associated with my child’s participation in the activities of the Camp and accept the inherent physical risks of these activities. By registering my child, I HEREBY CONSENT to his/her participation in the activities AND I FREELY ACCEPT all health and safety risks associated with his/her participation. I accept all liability for any loss of or damage to propert¬y caused by or contributed to by my child. Accordingly, I hereby release High Flyer Consulting Ltd. operating as Big Ben’s Camp its agents, directors, officers, and employees from any and all liability for any direct, incidental or consequential damages related to my child’s participation in the Activity. I FURTHER AUTHORIZE Big Ben’s Camp staff to take pictures of my child for identification purposes during his/her participation and for the Camp’s electronic and printed promotional material, including the Big Ben’s Camp website. ABILITY & BEHAVIOUR Big Ben’s Camp reserves the right to: assign the participant to a group most appropriate for their age or ability; to request any participant to withdraw from the camp if the participant is not behaving in an appropriate and reasonable manner. CANCELLATION In the very rare case where a program is cancelled because of low enrollment, we endeavour to give families as much notice as possible. We will transfer campers to another week of camp if families are interested and space allows. Otherwise, we will provide you with a full refund. WITHDRAWAL / TRANSFER POLICY Withdrawal from camp after June 20th is subjected to a $25 administration fee. No refunds or transfers after this date, unless approved by Camp Coordinator. THIS WAIVER OF LIABILITY AND RELEASE is effective throughout the camp session for which my child is registered and may not be revoked, altered, amended or avoided at any time. I understand and agree to the above.* Yes No Please type signature to agree* Date* ANAPHYLAXIS ACTION FORMChild’s Name* First Last Date of Birth* DD slash MM slash YYYY Gender* Male Female PARENT/GUARDIAN NAME* Main Contact #*EMERGENCY CONTACT NAME* Main Contact #*What is your child allergic to?*Medication (name and how it is administered):*EMERGENCY PLANWill Epi-pen be brought to Camp everyday?* Yes No Epi-Pen location* (Recommended that child carry Epi-Pen and show coach where it is located upon arrival and/or it is placed in the camp emergency first aid pack)Please state reason:* ANAPHYLAXIS PREVENTION STRATEGIES PARENT RESPONSIBILITIES Ensure Epi-pen is packed in appropriate location and sent to camp every day Inform staff of allergy, emergency treatment and location of Epi-pen Encourage child to wear a medical Alert bracelet or necklace Ensure child with food allergies only eats food/drinks prepared from home Discuss appropriate location of Epi-pen with the child and staff Epi-Pen must be labeled with Child’s Name STAFF RESPONSIBILITIES Camp coordinator to review Anaphylaxis Action Forms at the beginning of each day Inform all staff of each camper’s allergies at the beginning of each day Review Anaphylaxis Action Plan and location of Epi-pen(s) at the beginning of each day with all staff Remind children NOT to share food, drinks or utensils prior to lunch Encourage children to wash/disinfect hands before and after meals/snacks Provide alternative eating environment for campers who have allergens included in their lunch/snacks STANDARD EMERGENCY PLAN: Administer epinephrine auto-injector (Eg. Epi-pen or Allerject) Call 911 Notify Parents Ambulance transports child to hospital Please type signature to agree* Date*
