CAMPER INFORMATION
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First Name
Last Name
Gender
Male
Female
Date of birth
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MM
DD
YYYY
Age (as of July 15, 2024)
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Photo of your child (Please upload a photo of your child using the following file naming protocol: First Name_LastName. The maximum file size if 5MB per file. This photo will be used for identification and safety purposes.)
FileField; MaxSize=5000KB; Multiple; addText=Upload_Child's_Photo
T-Shirt Sizing (All campers will receive a special Pokrova 2024 camp t-shirt. Please choose the appropriate t-shirt sizing for your child.)
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Youth XS
Youth S
Youth M
Youth L
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Approximate Camper Height (cm/in)
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Previous Pokrova Camp Experience
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Yes
No
If yes, what year(s)?
OHIP #
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Other health card # (e.g. Quebec card)
PARENT/GUARDIAN - 1
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First Name
Last Name
Primary point of contact
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I am the primary point of contact for all matters concerning the camper during Pokrova 2024 Camp.
Relationship to child
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Daytime Phone
Cell Phone
Email
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PARENT/GUARDIAN - 2
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First Name
Last Name
Primary point of contact
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I am the primary point of contact for all matters concerning the camper during Pokrova 2024 Camp.
Relationship to child
*
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Daytime Phone
Cell Phone
Email
*
MEDICAL: Does your child have any allergies, conditions, dietary concerns that Pokrova Camp administration need to be aware of that could potentially impact upon your child’s camp experience?
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Yes
No
If yes, provide details.
Medications: Does your child take any medications?
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Yes
No
If yes, provide details. (Name, dosage required & condition being treated)
Do you need to restrict the child’s activities for medical reasons?
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Yes
No
If yes, please indicate details of restrictions and when applicable
Are Ottawa Public Health required immunizations up to date for your school-aged child?
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Yes
No
Date of last tetanus shot (Month and Year)
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Are there any other health-related concerns that Camp administration should be aware of related to your child?
FAMILY PHYSICIAN
First Name
Last Name
Physician's telephone
GENERAL INFORMATION (For curriculum programming only) - Languages - Does your child speak ...?
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English
French
Ukrainian
Other
My child’s first/primary language is
English
French
Ukrainian
Other
As we prepare to host your child at Camp, it is really helpful for us to learn about bit more about your child. Please share with us your child’s interests and hobbies, as well as help us to understand how they relate to others in social settings (outgoing, shy, extroverted, introverted, etc.).
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Does your child have any dance experience?
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Yes, my child has taken previous dance lessons.
No, my child has not taken previous dance lessons.
If yes, please tell us a little more about your child’s dance experience and the length of dance experience.
Does your child have any Ukrainian dance experience?
Yes
No
If yes, please tell us a little more about your child’s Ukrainian dance experience and the length of dance experience.
Does your child have any experience playing musical instruments?
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Yes
No
If yes, what instrument and for how long?
DROP OFF/PICK UP INFORMATION: Drop off - Name of Parent/Guardian
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First Name
Last Name
Relationship to child
*
Pick up - Name of Parent/Guardian
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First Name
Last Name
Relationship to child
I acknowledge that only the designated parents/guardians can sign out the camper during the week of Camp. If an alternate pick up arrangement with an adult authorized by me needs to be made for my child during Camp, I agree to provide this instruction to Camp administration by email in writing to the camp e-mail as follows: pokrovanetwork@gmail.com in advance of the pickup day.
I understand that without expressed consent in writing, in advance, children will not be released from Camp with any other adult other than the parents/guardians listed officially on this camper registration form.
IN CASE OF EMERGENCY (Other than parents) - Name
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First Name
Last Name
Relationship to child
Home Phone
Work Phone
Cell Phone
PAYMENT OF CAMPER REGISTRATION FEES - All payments for Pokrova Camp 2024 must be received in the form of an e-transfer to pokrovanetwork@gmail.com. Once the e-transfer has been sent, please email pokrovanetwork@gmail.com and providing the following information: Name of Camper: Date of E-Transfer: Transfer Confirmation Number (provided by your bank as the time of processing the e-transfer): Pokrova Camp 2024 offers a pro-rated fee (10% reduction) for families that are registering more than one child. Camp fees are as follows: First child registration - $390 CAD, Second and subsequent child registrations - $351 CAD. Please note that this reduction does not apply to families that are requesting financial assistance with camp registration fees.
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First child - $390 CAD
Second child - $351 CAD
Third child - $351 CAD
I am paying the Pokrova Camp 2024 registration fee for my child using e-transfer to pokrovanetwork@gmail.com. I will keep a record of my payment to Pokrova as proof of payment.
MEDIA CONSENT - I hereby consent to the use of any photographs/video taken of my child(ren) by the Pokrova Children’s Ukrainian Arts Camp, the Pokrova Ukrainian Arts Network and local, national or international media, for the purpose of advertising or publicizing events, activities, facilities and programs of the Network and its activities in print, digital and other communications and advertising media.
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Yes, I hereby consent to the above.
No, I do not consent to the above.
Date of application
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MM
DD
YYYY