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Inscription form Mohiganech Day camp
Kinder garden to Grade 6
*
Indicates required field
First name of the child
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Select one Nation
*
Algonquin
Cree
Attikamek
Hurons-Wendat
Malécites
Micmac
Mohawk
Montagnais
Naskapi
Inuit
Abénaqui
Métis
Allochtone
Other...
Last name of the child
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Other (specify)
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Age
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Gender
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Female
Male
School degree in september 2019
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Health Insurance Card number
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Twelve (12) numbers
Does your child have any known allergies?
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Does your child suffer from asthma?
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Yes
No
Does your child suffer from diabetes?
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Yes
No
Does your child received his/her tetanus shot?
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Yes
No
Does your child take medication?
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Yes
No
Medication list
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Special recommandations and others important elements that should be mention to us
*
Exemple: ADAH, ADA, etc.
Water safety
*
Swim alone
Swim with a life jacket
* Note that wearing a life jacket is OBLIGATORY for ALL children when they swimming at the cultural site, if they has no life jacket or he refuse to wear it, he can't swim, for his safety.
Does the child have a bike?
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Yes
No
Person to contact in case of emergency
Last and first name
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Relationship with child
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Phone Number
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Last and first name
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Relationship with child
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Phone Number
*
Last and first name
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Relationship with child
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Phone Number
*
As a parent, I take the responsibility to inform the day camp animators and/or community organizer, in person, by mail, by phone or by a note, of the absence of my child a day or the delay cause the animators must provides activities and transport as the number of children.
Is the child allowed to leave the premises alone?
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Yes
No
people authorized to pick up the child other than the child's parents
Last and first name
*
Exemple: hunt, uncle, grand-parents, sister/brother, etc.
Last and first name
*
Last and first name
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Last and first name
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Please check the week your child will attend
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WEEK OF JULY 2th 2019
WEEK OF JULY 8th 2019
WEEK OF JULY 15th 2019
WEEK OF JULY 22th 2019
WEEK OF July 29th 2019
WEEK OF AUGUST 5th 2019
Parents identification
Last and first name of the mother
*
Last and first name of the father
*
Address
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Line 1
Line 2
City
State
Zip Code
Country
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone number
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Work/Cell phone
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Email
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Phone number
*
Work/Cell phone
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Email
*
Authorizations
I authorized the Val-d'Or Native Friendship Center employees to give to my child, if necessary, some medication without prescription and sunscreen.
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Yes
No
Exemple: Advil, Gravol, etc.
I authorize the day camp animators to ensure that my child receives all necessary care. I also authorize them to transport my child by ambulance or other wise (at my expense) and him admitted to a health facility. In case of emergency or if you can't reach us, I authorize the doctor to provide all medical care required by his condition, including surgery, transfusion, injections anesthesia, hospitalization, etc.
*
Yes
No
In order to help the Mohiganech day camp to promote their services, I authorize the day camp employees to use the pictures or videos taken of my child during the day camp. These pictures or videos may be used to produce promotional tolls for the Val-d'Or Native Friendship Center
*
Yes
No
I accept that my child uses the Center's transportation and taxi 24 for the Mohiganech day camp outing activities.
*
I agree
The Val-d’Or
Native Friendship Center can’t be liable for any loss, theft or accidents.
Having read all the information, I authorized my child to participate at the day camp at the Native Friendship Center.
Submit