Welcome back & thank-you for taking the time to fill out another form! A registration form must be fully completed for each child who will be attending Camp Kerry.

Camper Information

 

To ensure that our database recieves all of your information correctly, please DO NOT USE the same email address to complete forms for multiple family members. If you don't have a personal/seperate email acount for each registrant then please complete the email section with the child's first name followed by @testemail.com.

 
For example: john@testemail.com
Country
State / Province*
Address
City
Email*
Confirm Email*
Phone
Date of Birth: dd/mm/yyyy*
If so, what year(s)?
  • 2007
  • 2008
  • 2009
  • 2010
  • 2011
  • 2012
  • 2013
  • 2014
  • 2015
  • 2016

Loved One Remembered

Tell us the first & last name of the person your child is remembering:*
Date of Loss: dd/mm/yyyy*
If there have been multiple losses please tell us who with the same information as you provided above.

Health Information

One of our top priorities is to do whatever we can to keep our program participants safe and reduce risks of injury. In the event of an emergency it is important for us to be prepared so that we can respond quickly. Completing all the information fields in this section will assist us in keeping your child safe.

PHN Care Card Number
Family Doctor Name
Family Doctor's Phone Number
Name of Emergency Contact
Phone Number of Emergency Contact
Emergency Contact's Mobile Number
If your child is currently on any medications please list them here.
Please select any that apply to your child.
  • Allergies
  • Allergies: Penicillin
  • Allergies: Seasonal
  • Anxiety
  • Asthma
  • Bed-Wetting
  • Crohns/Colitis/IBS
  • Depression
  • Diabetes
  • Ear Infections
  • Eating Disorder
  • Epilepsy/Seizures
  • Fainting
  • Hearing Impaired
  • Heart Disease/Condition
  • Hepatitis
  • High Blood Pressure
  • HIV
  • Learn Differently (Learning Difficulty)
  • Mobility Impairment
  • Motion Sickness
  • Nightmares/Terrors
  • Nose Bleeds
  • Phobias
  • Pregnant
  • Sleep Apnea
  • Sleepwalking
  • Visual Impairment
  • Other
If your child uses any assistive devices please indicate below.
  • Asthma Inhaler
  • Cane/Walker
  • CPAP Machine
  • Dental Braces/Caps/Bridges
  • EpiPen
  • Glasses/Contacts
  • Hearing Aids
  • Insulin Dependent
  • Oxygen
  • Prosthetic Device
  • Wheelchair/Scooter
If there are any activities that your child should be restricted from please tell us here.
Anything else you want us to know regarding your child's health?

I agree to give permission for the nurse and/or qualified personal to administer prescriptions, over-the-counter medications, first aid and/or access to medical treatment to my child, if needed.

Dietary Requirements

Not only do we want to ensure that all of our particpants at camp are safe, but we also want to do our best to provide meals that can be enjoyable regardless of any allergies, sensitivities, or restrictions. Tell us if your child has any special dietary requirements in this section.

Allergies/Sensitivities/Requirements
  • Peanut Allergy
  • Other Food Allergy
  • Gluten-Free Diet Required
  • Lactose-Free Diet Required
  • Vegan Diet Required
  • Vegetarian Diet Required
Additional Dietary Instructions/Information about my child that I want the Camp Kerry team to be aware of.

Photo & Video Permission

In order to capture memories and document activities we frequently arrange for pictures and videos to be taken of participants in our programs and at events our organization is associated with.

These images/videos are generally utilized for a variety of purposes including; Promotion of the Camp Kerry Society, Educational Purposes, Project Evaluations, and most often they are shared amongst other fellow participants. These photographs and videos may also be used for external public viewing on our website and/or other platforms of social media, in promotional materials, and by news media for Camp Kerry Society related stories.

If you consent to have photo/video images of your child used as noted above then please select the "Permission Granted" option below. If for any reason you don't want us to use these images/photos then please select "Permission not granted".

Acknowledgement of Risk & Release of Liability

In consideration for my child's participation in the Camp Kerry Society Programs and/or events, I hereby release, hold harmless and indemnify the Camp Kerry Society, its members, officers, directors, employees, volunteers and independent contractors, from all liability, claim, causes of action of any kind whatsoever in respect to all personal injuries, loss of life or property losses which I may suffer arising out of the activities of the programs/events. That I do hereby acknowledge and agree that the activities such as those listed may be dangerous and expose my child to risks and hazards: lifting & carrying supplies/equipment, participating in adventurous activities such as; swimming, hiking, climbing wall, ropes course, canoeing, kayaking, ball sports, campfire, horseback riding, fishing and that other activities designed to address grief and loss such as; sharing circles, memory services, and memorial activities, may elicit emotional discomfort. That I freely and voluntarily assume all of the aforesaid risks and hazards for my child. That I have carefully read this release, waiver, and assumption of risk agreement, that I fully understand same, and that I am freely and voluntarily executing same. That I clearly understand that by agreeing to this release, I will be forever prevented from suing or otherwise claiming against the Camp Kerry Society, its members, officers, directors, employees, volunteers, or independent contractors with respect to any matter arising from these activities.

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