Family Advancement Association                                                Kids Summer Program (FAAKSP)                                                      REGISTRATION FORM
Date: July 18, 2022 - August 13, 2021     Monday - Friday   9:30am-3:30pm
Venue:  Canadian Imperial College: 11525 23 Ave NW, Edmonton, AB T6J 4T3

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Child's Name ( First, Middle & Last Names) *
Child's Gender *
Birth Date *
MM
/
DD
/
YYYY
Address (Street Address, City, Province, Postal Code) *
Parent/ Guardian #1 (First and Last Name) *
Parent/Guardian #1 Address (Street Address, City, Province, Postal Code) *
Parent/ Guardian #1 Cell Phone Number *
Parent/ Guardian #1 Work Phone Number
Parent/ Guardian #1 Home Phone Number
Parent/Guardian #1 Email *
Parent/ Guardian #2 (First and Last Name) *
Parent/Guardian #2 Address (Street Address, City, Province, Postal Code) *
Parent/ Guardian #2 Cell Phone Number *
Parent/ Guardian #2 Work Phone Number
Parent/ Guardian #2 Home Phone Number
Parent/Guardian #2 Email *
Child Lives with: *
Person Responsible for payment is: *
Emergency Contact #1 (First and Last Name) *
Emergency Contacts #1 Cell Phone Number *
Emergency Contacts #1 Work Phone Number
Emergency Contacts #1 Email *
Emergency Contact #1 Relation to Child *
Emergency Contacts #2 (First and Last Name) *
Emergency Contacts #2 Cell Phone Number *
Emergency Contacts #2 Work Phone Number *
Emergency Contacts #2 Email *
Emergency Contacts #2 Relations to Child *
Child's Medical Conditions or Injury (allergies, epilepsy etc.)
If your Child does have any Medical Conditions and/or Injuries, is there any medication they need to take?
Medical Emergency Contacts #1 Name
Medical Emergency Contacts #1 Phone Number
Medical Emergency Contacts #2 Name
Medical Emergency Contacts #2 Phone Number
Medical Emergency Contacts #3 Name
Medical Emergency Contacts #3 Phone Number
Health Insurance Information
Alberta Health Card Number
Name of Health Insurance Provider
Primary Physician Address
Primary Physician Number
Hospital Preference
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *
I understand that the FAA will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. *
I hereby give permission for my child to be photograph during FAAKSP. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports for our funders and for promotional purposes. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Family Advancement Association (FAA) *
I hereby give permission for the transportation of my child for official FAAKSP activities by modes of transportation agreed to by the camp organizers. *
The FAA is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). *
I understand that the registration fee of $50 per child to a maximum of $100 per family is required for the entire program. *
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