FMM Schools

2023-Birchwood Academy Summer Camp Registration Form

MMA - Birchwood Academy Summer Program Registration Form
Child's Name*
First Last
Age*
Sex*
- Male
- Female
Date of birth*
Date Format: MM slash DD slash YYYY
Registration Fee
Week 1 July 4th to July 7th
- Morning BASKETBALL -(8.30am-11.30am)-$90/Week
- Afternoon GO GREEN! -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
Week 2 July 10th to 14th
- Morning BASKETBALL -(8.30am-11.30am)-$90/Week
- Afternoon BON APPETIT! -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
Week 3 (July 17th to 21st
- Morning FITNESS FRENZY -(8.30am-11.30am)-$90/Week
- Afternoon MAD SCIENCE -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
Week 4 (July 24th to 28th)
- Morning FITNESS FRENZY -(8.30am-11.30am)-$90/Week
- Afternoon OCEAN EXPLORERS -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
Week 5 (July 31st to Aug 4th)
- Morning SOCCER -(8.30am-11.30am)-$90/Week
- Afternoon AROUND THE WORLD IN 5 DAYS -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
Week 6 (Aug 8th to 11th)
- Morning SOCCER -(8.30am-11.30am)-$90/Week
- Afternoon JURASSIC PARK -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
Week 7 (Aug 14th to Aug 18th)
- Morning SOCCER -(8.30am-11.30am)-$90/Week
- Afternoon ART WEEK -(12.30pm-3.30pm)-$90/Week
- CAMP DAY (8.30am-03.30pm)-$170/Week
- EXTENDED DAY (7.30am-05.30pm)-$220/Week
- N/A
STUDENT & FAMILIY INFORMATION
Mother/Guardian Information
Mother/Guardian Name*
First Last
House Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone*
Work Phone
Email*
Father/Guardian Information
Father/Guardian Name
First Last
House Address
Same as Mother/Guardian

Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Work Phone
Email
Emergency Contact
Name*
First Last
Relationship to child*
Home Phone
Cell Phone*
Work Phone
Email
Persons authorized to pick my child up

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Emergency Release
Consent to Emergency First Aid & Transportation:*
I hereby give permission that my child listed above may be given emergency treatment by Birchwood Academy staff member as deemed necessary. I also give permission for my child to be transported by car or ambulance to an emergency center for treatment, and agree to hold Summer Camp and its employees harmless. Any costs associated to medical care and treatment (including ambulance fees) will be the responsibility of the parent/guardian.
Signature*
Date
Date Format: MM slash DD slash YYYY
Medications & Health Information:
Medication required (epi - pen, puffer, etc.)?*
Yes
No
Name of medication*

Please complete medication form
Relevant health information (Medical condition )*
Any Allergies?*
Yes
No
Allergies (please list)*
Alberta Health Care Number*
Doctors Name*
Consent to Medical Care and Treatment
Please check the box beside the statement.*
In the event that I cannot be contacted immediately, medical of surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician, and I hold Birchwood Academy and its employees not negligent. Any costs associated with medical care and treatment (including ambulance fees) will be the responsibility of the parent/guardian.
Signature*
Date
Date Format: MM slash DD slash YYYY
Medication Administration
Please check the box beside the statement.*
I understand that Birchwood Academy can only administer medication when the Parent/Guardian has completed a medication administration form.
I understand that Birchwood Academy can only administer prescribed medications .I understand that Birchwood Academy will administer medication according to the directions on the label.
I understand Birchwood Academy will only administer medication provided in the original container.
I understand that when ongoing medication is required (i.e. Asthma medication or Epi-Pen) an Emergency Medication Administration form must be completed by the Parent/Guardian (and doctor, if requested).
Signature*
Date
Date Format: MM slash DD slash YYYY
Field Trip Permission
Please check the box beside the statement.*
I hereby permit that my child listed above can participate in spontaneous field trips to the local park or walks in the neighborhood that would involve taking the child outside of the camp premises for his/her benefit in attendance at this camp. If major field trips are planned, a separate permission form will be provided in advance for parents/guardians to sign. This form will include the date, transportation and supervision arrangements of the activity.
Signature*
Date
Date Format: MM slash DD slash YYYY
Photo & Video Permission
Please check the box beside the statement.*
Birchwood Academy uses photo documentation in order to track your child’s activities throughout the summer. We also use these photos for documentation panels throughout the camp location. Occasionally we would like to use photos on our social media and website, as well as including photos in our camp bulletin that will go home to enrolled families.
Signature*
Date
Date Format: MM slash DD slash YYYY
If there are custody orders please upload a copy here

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FMM Schools

2023-Birchwood Academy Summer Camp Registration Form

MMA - Birchwood Academy Summer Program Registration Form

STUDENT & FAMILIY INFORMATION

Emergency Contact

Emergency Release

Medications & Health Information:

Consent to Medical Care and Treatment

Medication Administration

Field Trip Permission

Photo & Video Permission

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