WDDS

Youth Camp fee is $250 per week and can be paid at our main office at: 212 Bysham Park Drive Woodstock, Ontario N4T 1R2 or by phone at 519-539-7447

I will call to provide payment

I will come to the main office to provide payment

Is this your first time registering your camper with WDDS?

Yes

No

First Name * *

Last Name * *

Gender *

Male

Female

Birthday * *

Address * *

Doctors Phone *

Doctors Name * *

Phone * *

Health Card Number (no spaces)* *

Health Card Version Number *

First Name *

First Name

Last *

Same Address as Camper

Parent 1 Address *

Parent 1 Phone Number * *

Work Phone *

Cell Phone *

Email *

Parent 2 First Name * *

Last *

Same Address as Camper

Parent 2 Address *

Phone Number * *

Work Phone *

Cell Phone *

Custody of Camper- Please Specify *

Both

Mother

Father

Other

First Name *

Last *

Relationship * *

Home Phone *

Work Phone *

Cell Phone *

Does your camper access services from any of the following:

WDDS' Family Support Program

Community Living Tillsonberg's Family Support Program

VON

Wellkin Child and Youth Mental Wellness

Do you consent for WDDS to contact any of the above services you access? This consent will expire August 23rd, 2019.

Yes

No

Does your Camper have any medical conditions we should know about?*

Yes

No

If yes, please specify: *

Does your Camper have seizures?

Yes

No

If yes, please specify what a typical seizure and recovery looks like: *

Does your Camper have any allergies?*

Yes

No

If yes, please specify what a typical reaction may look like. *

Does your Camper carry an EPI PEN?*

Yes

No

Does your Camper carry a medical alert bracelet?*

Yes

No

Does your Camper have a safety plan at school?*

Yes

No

Do you consent for WDDS to contact the school? This consent expires June 28, 2019.*

Yes

No

If yes, please specify the school and contact person and details of the plan. *

Does your camper understand street safety?*

Yes

No

Does your camper require assistance with eating?*

Yes

No

Does your camper have any concerns with food? Ie. dietary concerns or allergies.*

Yes

No

If yes, please specify *

Does your camper requires assistances to use the washroom?*

Yes

No

Does your camper require assistances with dressing?*

Yes

No

Does your camper require assistance with walking/assistive devices?*

Yes

No

Will your camper be arriving by taxi or para transit?*

Yes

No

If yes, please specify cab company and drop off and pick up times *

Please list any medications your Camper requires while at camp. Original containers and clearly labeled. *

Please complete for medial emergencies if your Camp is taking any consistent medications.

Name of Med #1 *

Dose *

Reason *

Name of Med #2 *

Dose *

Reason *

Name of Med #3 *

Dose *

Reason *

Name of Med #4 *

Dose *

Time of Administration *

Reason *

No Medication

Time of Administration *

The following questions help provide our camp staff information to plan for activities and match required support for your camper's needs. If no concerns or input please state in the box "no concerns". *

How do we support your Camper about street safety? *

What level of understanding does your camper understand personal space (toughing/hugging)? *

Please list the type of activities your Camper enjoys or any ideas your Camper may enjoy or like to try, *

Please describe how to best support your Camper with communicating with others. Do you have any suggestions that will help us to communicate with your Camper better? Does your Camper have communication device/picture board with them? *

Is there any other information that you think we should know to help support your Camper to have a great experience at camp? *

Does your Camper have any friends also attending our camp? Who? This helps with planning trips. *

Which weeks will your camper be attending?

July 2nd-5th (Eco Explorers)

July 8th-12th (Animal Planet)

July 15th-19th (Fit n' Fun)

July 22nd-26th (Science Rules!)

July 29th- August 2nd (Techtroplolis)

August 6th-9th (Edible Adventures)

August 12th-16th (Amazing Race)

August 19th-23 (Expressive Arts)

Name of Person to be Invoiced and email address:* *

Phone Number of Person to be Invoiced * *

Youth Camp Registration