Day Camp

First name of the child *

Select one Nation *

Last name of the child *

Other (specify) *

Age *

Gender *

School degree in september 2019 *

Health Insurance Card number *

Does your child have any known allergies? *

Does your child suffer from asthma? *

Yes No

Does your child suffer from diabetes? *

Yes No

Does your child received his/her tetanus shot? *

Yes No

Does your child take medication? *

Yes No

Medication list *

Special recommandations and others important elements that should be mention to us *

Water safety *

Swim alone Swim with a life jacket

Does the child have a bike? *

Yes No

Last and first name *

Relationship with child *

Phone Number *

Last and first name *

Relationship with child *

Phone Number *

Last and first name *

Relationship with child *

Phone Number *

Is the child allowed to leave the premises alone? *

Yes No

Last and first name *

Please check the week your child will attend *

Last and first name of the mother *

Last and first name of the father *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone number *

Work/Cell phone *

Email *

Phone number *

Work/Cell phone *

Email *

I authorized the Val-d'Or Native Friendship Center employees to give to my child, if necessary, some medication without prescription and sunscreen. *

Yes No

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

YOuth Action

Inscription form Mohiganech Day camp

Kinder garden to Grade 6

Person to contact in case of emergency

people authorized to pick up the child other than the child's parents

Parents identification

Authorizations