Backus Heritage Conservation Area

Backus Heritage Conservation Area
2013 Summer Day Camp at Backus Heritage Conservation Area
Summer is fast approaching and that means it is time to register for Heritage Day Camp!
This summer promises to be another fun-filled adventure at Backus Heritage Conservation Area
and we hope you will be able to join us!
This year each Thursday in July and August will be an adventure in time when campers explore weekly themes
and take part in a variety of activities.
Included in this package are the camp dates, as well as, some information on what to expect
to better prepare you for your time at Backus this summer.
Pre-registration and pre-payment are required for all day camps at least one week
in advance of the camp date.
Submit your completed registration form and payment by any of the following methods:
Mail: 1267 2nd Concession Road, RR#1, Port Rowan, N0E 1M0
Fax: 519-586-7333
Email: backus@lprca.on.ca
In person: at the Conservation Education Centre Office
Please note: No daily walk-ins will be accepted. Only those who are pre-registered and pre-paid.
Please fully complete the day camp registration form and medication administration form (if applicable).
If you have any questions or concerns, please do not hesitate to contact us.
Call 519-586-2201 or 1-877-990-9932 ext 3 and speak to Robin.
We are looking forward to seeing you at camp!
Backus...where history meets nature
Backus Heritage Conservation Area
2013 Backus Day Camp Schedule
Each Thursday in July and August will be an adventure in time when
campers explore weekly themes and take part in a variety of activities.
Heritage Day Camp
6 to 12 years old
Drop off 9:00 am and pick-up 4:00 pm at the
Forbes Barn in the Heritage Village.
Children become modern-day explorers discovering the past through
fun hands-on activities and outdoor adventures. Go behind the
scenes in the Heritage Village and experience life as it was in the
1860s. Campers will work and play pioneer style during the weekly
themed programs, including cooking on a wood stove, making unique
arts and crafts and playing old-fashioned games. Swimming, hikes
and themed dress-up days add to the fun!
Camp Dates
July 4: Strawberry Fields Forever
July 11: A Soldier’s Day
July 18: Moulded to Camp
July 25: Wild West Day
August 1: P is for Pioneer & Pizza
August 8: Pirate Daze
August 15: Bike it & Hike it
August 22: Gone Fishing
August 29: School Days
Cost: $32.50/child/day (taxes included)
No refunds except with a medical certificate or if program is cancelled by LPRCA.
Payment options include cash, VISA, MasterCard, Amex or Debit
No Walk-ins will be accepted. Only those who are pre-registered and pre-paid may attend.
Backus...where history meets nature
Backus
Day Camp Application 2013
www.lprca.on.ca
1267 2nd Concession Road, R.R. # 1 Port Rowan, Ontario N0E 1M0
Tel.: 519-586-2201 • Fax: 519-586-7333 • Email: bhca@lprca.on.ca
Heritage Conservation Area
Heritage Day Camp rEGISTRATION FORM
CHILD’S NAME
AGE
GRADE COMPLETED
HOME ADDRESS (STREET, CITY, POSTAL CODE)
FAMILY DOCTOR (NAME AND PHONE)
PLEASE TELL US MORE ABOUT YOUR CHILD
DOES YOUR CHILD HAVE A MEDICAL CONDITION?
□ YES
□ NO
IF YES, PLEASE COMPLETE ATTACHED “MEDICAL ADMINISTRATION FORM”
IS YOUR CHILD ON ANY MEDICATION?
□ YES
□ NO
IF YES, PLEASE COMPLETE ATTACHED “MEDICAL ADMINISTRATION FORM”
DIETARY CONCERNS
(i.e. allergies, dietary restrictions or conditions)
FEARS
(i.e. spiders, snakes, bees, thunderstorms)
WHAT IS YOUR CHILD’S SWIMMING ABILITY?
CONTACT INFORMATION
PARENT’S/GUARDIAN’S NAME (FIRST CONTACT)
HOME PHONE
CELL PHONE
WORK PHONE
EMAIL
PARENT’S/GUARDIAN’S NAME (SECOND CONTACT)
HOME PHONE
CELL PHONE
WORK PHONE
EMAIL
EMERGENCY CONTACT (IF PARENT/GUARDIAN CANNOT BE REACHED)
NAME
RELATIONSHIP
HOME PHONE
CELL PHONE
In my/our absence, I authorize the following people to pick-up my child (no others will be permitted to
pick-up your child, without prior consent):
CAMP DATES
SELECT CAMP DATES TO BE ATTENDED
□ July 4: Strawberry Fields Forever
□ July 11: A Soldier’s Day
□ July 18: Moulded to Camp
□ July 25: Wild West Day
□ August 1: P is for Pioneer & Pizza
□ August 8: Pirate Daze
□ August 15: Bike it & Hike it
□ August 22: Gone Fishing
□ August 29: School Days
SEE REVERSE
FEES- $32.50/CHILD/DAY (TAXES INCLUDED)
AMOUNT PAID
PAID BY:
□ CASH
RECEIPT NUMBER
□ DEBIT
□
VISA
□ MASTERCARD
□ AMEX
PERSONAL CHEQUES ARE NOT ACCEPTED UNLESS CERTIFIED
AUTHORIZATION
If at any time emergency medical treatment is necessary for my child, I give my consent for treatment to be
given. Every effort will be made to contact parent/guardian(s) and/or emergency contacts.
PLEASE INITIAL IN CONSENTED SPACE:
YES __________ NO ___________
PHOTO RELEASE
□
I am aware that photographs and/or videos taken of my child during camp may be used by the Long Point
Region Conservation Authority for promotional purposes (e.g. newspapers, LPRCA publications, website).
□
No, I do not want my child photographed or filmed for any purpose whatsoever.
SIGNATURE OF PARENT/GUARDIAN _____________________________________________
CONSENT FORM
Please note that Long Point Region Conservation Authority and Backus Heritage Conservation Area are
not responsible for any accident, injury or loss, howsoever sustained, to your child or child’s property,
or for personal injury or mishap. Programs include outdoor hikes on our trails, crafts, active games,
swimming and activities, as well as, short audio-visual components to reinforce concepts and themes. The
parent/guardian is assuming full responsibility for the applicant’s health being such that the activities will
in no way aggravate any conditions or will seek advice before completing this form. All activities are at the
risk of the participant. If you do not wish your child to participate in an activity, please notify camp staff.
I have read the liability statement and agree that my child may participate in all Heritage & Nature Day Camp
activities.
Signature of Parent/Guardian __________________________________ Date _____________________
The information on this form is collected under the legal authority of the Conservation Authorities Act
R.S.O. 1990, c.27, and will be used for administrative purposes and to provide you with updates regarding
programs and facilities at Backus Heritage Conservation Area. Your personal information is not shared with
any third party.