March Break STEAM Camp Registration Form

Address (street number and name):*

I understand I will need to bring my child’s/children’s healthcare card in on the first day of camp. *

Where did you hear about our program?*
Tropicana WebsiteTropicana BulletinTropicana Social MediaFacebookInstagramLinkedinTropicana Staff MemberOtherIf other, please explain:

Have your child/children participated previously in Tropicana Programs? Please indicate yes or no.*
NoYes. Please describe

Activity Permission: I hereby consent and grant permission for myself/my child to participate in all program activities unless I advise you otherwise, in advance, in writing.*
AgreeDo not agree

Media Release: I hereby consent and grant permission for Tropicana Community Services, their event partners and respective media representatives may take pictures, videotape or digitally record my child/children while they are engaged in their program activities and also authorized to use these for any promotional outreach or advertising purposes. (If you do not consent to this for whatever reason, please inform us about your objection).*
AgreeDo Not Agree. Please explain below:

Provision of Care/Emergency: I confirm that I have provided Tropicana Community Services with accurate contact, childcare, and medical information. In case of emergency, I authorize Tropicana Community Services Organization to secure medical care for my child/children. I hereby waive any claim against Tropicana Community Services Organization, event partners, volunteers and/or their staff which may arise from any injury my child/children may incur as a result of their participation in program activities.*
AgreeDo not agree

Transportation/Schedule: I will be responsible for getting my child/children to the camp site on time at 8:45 a.m. and picking them no later than 4:15 p.m. I will also provide my child with the necessary supplies, as noted by Tropicana, and as required.*
AgreeDo not agree

Food Provision: will provide my child/children with enough food, snacks, and water each day as needed. I understand that Tropicana is a seafood and shellfish-free facility, and I will not send any food containing nuts or peanuts.*
AgreeDo not agree

Reschedule/Refund Policy: I understand Tropicana does not provide refunds for missed or half days.*
AgreeDo not agree

Declaration:
I understand that my place is not saved until I have received confirmation from Tropicana's March Break Team, and have paid the $75.00/per child registration fee.

Do you want to sign up to receive emails from Tropicana?*
I would like to receive communications from Tropicana Community Services. I understand that I can unsubscribe at any time.I do not wish to receive any communications from Tropicana Community Services.

Date of Birth (day/month/year):*

Gender:*
MaleFemaleNon-BinaryPrefer not to say

Ethnicity:*
Black (African, African-Canadian, Afro-Caribbean, Afro-Latin)Indigenous (First Nation, Inuit, Métis, non-status)South/East Asian (examples: Filipino, Chinese, Japanese, Korean, Malaysian, Singaporean, Thai, Vietnamese)Latin American (examples: Brazilian, Colombian, Cuban, Mexican, Peruvian)White (English, Greek, Italian, Portuguese, Russian, Slovakian)South Asian or Indo-Caribbean (examples: Indian, Indo-Guyanese, Indo-Trinidadian, Pakistani, Sri Lankan)OtherPrefer not to say

Does this child require counselling for emotional, behavioral, or mental health concerns? Please indicate yes or no. If yes, please specify: *
NoYes (explain below)

Does this child have any allergies? If yes, please specify.*
NoYes. Please explain.

Does this child have any anaphylactic (life-threatening) allergies? If yes, please list the anaphylactic allergy, type of auto injector EpiPen (adults or junior), and type of auto injector allerject (adult or junior).*
NoYes

Has this child received a diagnosis of Attention Deficit Disorder (ADD) or ADHD?*
NoYes

Has your child participant received a psychiatric diagnosis, such as depression, OCD, or panic/anxiety? Please indicate yes or no. If yes, please specify:*
NoYes. Please explain.

Does this child see (or has seen) a professional healthcare practitioner (physical and/or mental health) to address mental/emotional concerns? Please indicate yes or no. If yes, please specify:*
NoYes. Please explain.

Has this child required counselling for emotional, behavioural, or mental health concerns? Please indicate yes or no. If yes, please specify.*
NoYes. Please explain.

Does the child have any learning disabilities? Please indicate yes or no. If yes, please specify.*
NoYes. Please explain.

Does this child have any physical disabilities? Please indicate yes or no. If yes, please specify. *
NoYes. Please explain.

Are there any restrictions to activities or any accommodations required for full participation in the program? Please indicate yes or no. If yes, please specify what adaptations or limitations may be necessary.*
NoYes. Please explain.

Does this child currently take any medication (including non-prescription drugs) at home or on a regular basis? If yes, please specify: *
NoYes. Please explain.

Is this child permitted to go home on their own?*
NoYes, I will provide a written note for the specific day(s)

Signature of Parent/Guardian (type your full name): *