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	Program Registration Form Choose Program Select Highlands June Sampler Camp Highlands Wilderness Adventure Camp Highlands Fun on the Farm Camp Highlands Planet Spectacular Camp Highlands Jr Leadership and Backpacking Camp Highlands Bike and Biathlon Camp Child First Name: Child Surname: Address: City: Postal Code Home Phone: Email Address: Age: Week(s) your child will be attending: Emergency contact #1 Contact Name: Contact Relationship: Contact Home Telephone: Contact Work Telephone: Emergency contact #2 Contact Name: Contact Relationship: Contact Home Telephone: Contact Work Telephone: Health Information Child DOB: Health Card # Physician Name: Physician Telephone: Dentist Name: Dentist Telephone: Allergies Food: Insect bite: Drug: Carries Epipen: Yes No Please List specific allergies: Please list specific reactions: (ie. rash, swelling, etc.) Other Health Concerns Is your child under any form of treatment/medication for any illness, condition or injury?  Yes No If yes, please explain. Please describe health concerns and any special care that your child may require Behavourial Concerns Are there any behavioural concerns our staff should be aware of with regards to your child? Yes No If yes, please explain. Medication Release I request that medication be administered to my child as stated above and hereby release Highlands Nordic Ski and Outdoor Centre from all claims for loss or injury that may result  I agree I do not agree Informed Consent In consideration of my child’s attendance and participation at the Highlands Nordic Ski Centre day camp program, I hereby acknowledge that certain risks of injury are inherent in participation in sports and/or recreational activities. I agree that Highlands Nordic Ski Centre or its employees shall not be liable for any injury to my child or loss or damage to my child’s personal property arising from my child’s participation in these activities. I understand that I am responsible for informing Highlands Nordic Inc. of any medical conditions my child has and for completing and returning a medical information sheet. I agree Photo Release Permission is given for use of any photos of my child to appear in future camp brochures or other material produced by Highlands Day Camp and/or Highlands Nordic Ski Centre. I agree I do not agree Parent or Guardian's name submitting this form:

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