Summer Camp Registration Form

Camper Information

Camper's Name*

First NameLast Name

Birth Date*

MonthDayYear

Today's Date

Date

Calculated Age

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is there any additional information we should know about your child?

Parent/Guardian Information

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

E-mail*

How did you hear about us?*

Emergency Information

Emergency Contact's #1 Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Emergency Contact's #2 Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Please list the full names of ALL persons who are authorized to pick up your child. Please include your name as well. *

My Products

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Media Release

Little Medical School of Waterloo Region is granted permission to take photographs/videos of my child(ren) to use in brochures, websites, posters, advertisements, social media, and other promotional materials they create. Permission is also hereby granted for Little Medical School of Waterloo Region to copyright such photographs in its name.

Do you give photo consent for your child?*

YesNo

Participation Waiver for Little Medical School Camps

I understand and agree:

1) That I, or my child(ren) am in proper physical condition to participate in this program.

2) That all activities in the program are optional and that certain activities in the program require a minimum level of fitness to participate.

3) That Little Medical School of Waterloo Region, nor its agents or employees, will not be responsible for any injury that occurs during the program.

IN CONSIDERATION of participating in the above noted program and by agreeing to this waiver for myself (or for the named participant, if the participant is under 18 years of age) I, for myself, my heirs, executors, administrators, successors and assigns, release, waive and forever discharge Little Medical School of Waterloo Region and all of its employees, agents, servants and sponsoring companies, and elected and appointed officials, successors and assigns of and from all claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect of injury, loss or damage to my person or property however caused, arising or to arise by reason of my participation in this course, or in any activities associated with this program.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Little Medical School Camp Registration