BRANCHING OUT HOME

BRANCHING OUT- SUMMER THERAPEUTIC CAMP
CAMP LOCATION: *
 Brampton- Play Daze July 4-8 
 Brampton- Teen Quest Camp Aug 2-5 
 Brampton- Play Daze Aug. 29 - Sept. 2 
 Algonquin- July 11-15 
 Algonquin- July 18-22 
 Algonquin- August 8-12 
 Algonquin- August 15-19 
 Algonquin- Teens July 11-15 
 Algonquin- Teens August 8-12 
CAMPER NAME: *

First
Last
DATE OF BIRTH: *

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AGE:
(at the time of program)
ONE-TO-ONE
Please indicate if your child requires one-to-one Programming for their special needs.
ALLERGIES:
 EPI-PEN REQUIRED 
 NUTS 
 EGGS 
 DAIRY 
 GLUTEN 
 PET DANDER 
 ENVIRONMENT 
 OTHER 
Please indicate any allergies your child may have.
MEDICATIONS:
Please indicate if we are required to administer medication during Camp Hours.
MEDICAL INSTRUCTIONS:
Please provide clear instructions on how and when to administer all medications. All medications must be clearly labelled and in a ziplock bag.
EMERGENCY CONTACT:
(Parent/Guardian) *

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First
Last
Suffix
HOME PHONE: *

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CELL PHONE:

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EMAIL CONTACT:
CASE MANAGER:
CAMPER DETAILS:
Please tell us a bit about your camper (first time camper, swimming ability, special interests or skills) that will help us in our preperations towards a positive camping experience for your child. Please include any special direction or instructions in handling your child.
REFERRAL SOURCE: *
PHOTOGRAPHS: *
 Yes, I give permission for my child to be photographed 
 No, I would prefer my child not be photographed 
AUTHORIZATION: *
 Yes as legal parent/guardian I accept the terms of this application. 
By submitting this form you are authorizing your named child above to attend and be apart of the Branching Out program named. By submitting this form you are also with the understanding that the Branching Out staff will supervise all activities and you have given authorization for the Branching Out staff to administer emergency medical treatment or involve a professional medical staff if required.
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