2019 EMERGENCY FORM

Name Phone (_____) _____-_______

Name Phone (_____) _____-______

Name Phone (_____) _____-______

Please note there will be an additional charge of $1.00 per minute for each late pick-up after 5 pm.

I hereby give permission for __________________________________________________________________ to (check off the following): Child’s name

Have Discovery Centre staff administer appropriate first aid and CPR if necessary.Be taken to the hospital for treatment if required.Be photographed or filmed by media or Discovery Centre staff, and to have these images be used for any of Discovery Centre’s publicity needs including television, print and/or any other publications.Be photographed by DC Camp Staff for camp slideshow and campus use only.Attend all field trips off Discovery Centre premises

Parent / Guardian _____________________________________________________________ Date ______________________

By returning this form, you are acknowledging that Discovery Centre camp staff has permission to use all information listed above when your child is in their care.

PLEASE DOWNLOAD THIS FORM AND EMAIL TO hyuill@thediscoverycentre.ca This form will be kept on file and will be valid for all camps attended by the child listed above for the duration of the calendar year, with the exception of our summer camps. Please notify staff of any changes as soon as possible. A new form will need to be completed for summer camps and for any camps attended in future calendar years.

The information we collect from you is protected under the Privacy Act (PIPEDA) implemented on January 1, 2004. We collect and safeguard this information to fulfill our commitment to customer service. If you wish to be removed from our mailing list, please contact us; otherwise we will continue to send you items that we feel may be of interest to you. If you have any questions, please contact: Privacy Officer, Discovery Centre, 1215 Lower Water Street, Halifax, NS B3J 3S8.

Please notify camp staff immediately if there are any changes to the following information. Child’s

Name _______________________________________________________ Birthday (dd/mm/yyyy) _______________

Parent/Guardian’s Name

Address Postal ______________________

Phone (h) (_____) _____-______ (w) (_____) _____-______Email ____________________________________________________(c) (_____) _____-______ Please indicate which phone number is the most reliable.

Emergency Contact (other than parent or guardian) Relationship to child ______________________________

Name ___________________________________________________ Home (_____) _____-______Work (_____) _____-______

Medical Information Medical Conditions, including allergies ______________________________________________

______________________________________________________________________________________________________________

Doctor’s Name ____________________________________________________ Phone (_____) _____-______

Pick-up The following people have permission to pick up my child: