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Coding and Computer Science for Kids
Please complete the registration form below
Camp Location
*
St. Vital
East-Kildonan
Camp Week(s)
*
July 8-12
July 15-19
July 22-26
July 29 - Aug 2
Aug 5-9
Aug 12-16
Aug 19-23
Primary Contact (Guardian)
Primary Contact Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Relationship to camper
*
Camper
Camper Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Other
Address
*
Alternate Contact
Alternate Contact
*
First Name
Last Name
Phone
*
(###)
###
####
Relationship to Camper
*
Emergency Contact / Pickup
This is a person over the age of 16 who is authorized to pick up your child and can be contacted by Code Cobra staff when the parent/guardian can’t be reached.
Contact info
*
If same as primary or alternate, you may leave below fields blank.
Same as primary
Same as alternate
New contact (fill below)
Emergency Contact
First Name
Last Name
Phone
(###)
###
####
Secondary Phone
(###)
###
####
Email
Relationship to Camper
Are there any court orders or custody restrictions which would prevent us from communicating with either parent/guardian?
*
(If yes, we will contact you for additional information.)
No
Yes
Do you consent to Code Cobras taking photographs or video of the camper for its own use, including promotional material?
*
Yes
No
Do you consent to Code Cobras setting up a coding account for the camper with the coding platforms used in camp?
*
Yes
HEALTH HISTORY AND PERSONAL INFORMATION
The more information you can provide, the better we can meet the needs of your child. This information will be used by the Day Camp Director, and your child’s counselors to support your child.
Is the participant under any form of treatment for an illness, condition or injury?
*
No
Yes
If yes, please explain:
Does your child have any medical or behavioural conditions that we should be aware of?
*
No
Yes
If yes, please explain
Does your child use a puffer?
*
No
Yes
Does you child carry an Epi‐pen?
*
If your camper carries an epi-pen, you will be asked to fill out an anaphylaxis plan form when you drop them off on the first day of camp.
No
Yes
Does your child wear a Medic‐Alert Bracelet?
*
No
Yes
If yes, please provide as much detail as possible
Restrictions (please provide details below):
*
None
Gluten free
Lactose intolerant
Vegetarian
Other
If other, please explain
HEALTH CARD INFORMATION
Health Registration Number (6 digits)
*
PHIN (9 digits)
*
MEDICAL EMERGENCIES
In the event of an accident, injury or illness involving the registrant, and immediate contact by Code Cobras with a designated contact cannot be made, I hereby authorize and grant permission to Code Cobras staff to secure proper medical treatment and authorize on the registrant’s behalf all procedures, including, without limitation, admission to an emergency unit, hospital and treatment therein, ordering of x‐rays, tests or treatment, injections, anesthesia and/or surgery, as deemed necessary by the attending medical professional(s). I agree not to hold Code Cobras or its parent company responsible for any costs or injury arising out of an emergency situation.
CODE OF CONDUCT
The safety of everyone in the program is of utmost importance to Code Cobras. Each registrant takes responsibility to learn and follow at all times the safety and other rules established by Code Cobras staff. I hereby agree that any behaviour of the registrant that places him/her or others at risk may result in the registrant’s immediate dismissal from the program. Further if dismissed from the program I agree to cover any expenses arising from such dismissal. I hereby acknowledge and agree that no refund will be granted for dismissal or removal of the registrant at his/her request before the end of the camp. In order to ensure the safety and well being of all individuals participating in the program, Code Cobras reserves the right to alter the program at any time without notice of compensation to the registrant. By completing this form you acknowledge that (1) you are over the age of majority in your jurisdiction of residence and that (2) you are registering on behalf of a minor and are his/her parent/legal guardian and as such are fully authorized and entitled to enter into this agreement on his/her behalf.
CONSENT
Summer day camp carries some risks of injury. I hereby certify that I know of no medical problem which would increase my child’s risk of illness and injury as a result of participation in day camp and the sports and physical activities included in the camp program. By submitting this form, I state that I understand the risks and benefits my child may experience with exercise. I waive any responsibility of Code Cobras management and staff should my child should incur any injury as a result of participating in the Code Cobras summer camp.
Thank you for submitting your registration form!
