1) Child's Name*

First Name Last Name

Date of Birth*

Date

2) Child's Name

First Name Last Name

Date of Birth

Date

3) Child's Name

First Name Last Name

Date of Birth

Date

4) Child's Name

First Name Last Name

Date of Birth

Date

Parent/Guardian Name*

First Name Last Name

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number*

Area Code Phone Number

E-mail*

Physician Name*

Physician Number*

Medical Concerns, Required treatment, name of child (if more than one). Should ambulance be called?

Is your child presently being treated for an injury, illness or taking any form of medication? If yes, please explain.

Does your child require a special diet? If yes, please explain.

Name*

Contact Number*

Email

Relation to Child(ren)*

Not including the parent/guardian listed above, please list any additional persons permitted to pick up your child/children:

Will you require FULL DAY care for your child/children (8:30am- 4:30 pm)?*

YES NO

Each week has a different theme. Please indicate the week(s) you are registering for:*

Week 1- July 6-9 The World Around Us Week 2- July 12-16 Eco Arts & Craft Week 3 - July 19-23 In the Soil Week 4 - July 26*-30 Healthy Kids Week 5 - August 3-6 Be a Planeteer! Week 6 - August 09-13 Active Kids Week 7 - August 16-20 Splishy Splash! Week 8 - August 23-27 Eco Kids

$90 per child/ per week.

Eco Kids Summer Workshops Series

CHILD/CHILDREN INFORMATION:

PARENT/GUARDIAN INFORMATION:

Medical Information

Emergency Contact

Registration and Payment