2023 ARC Camp Connect Registration Form

Participant Information

First Name: *

Last Name: *

Date of Birth: *

Home Address

City

State/Province

Zip/Postal

Diagnosis: *

Allergy: *

Reaction:

Hospitalization #: *

Physician's Name: *

Physician's Phone Number:

School Name: *

Teacher: *

Name of Autism Centre Clinician/Social Worker:

Ethnic Background: (must choose one from below) *

Would you like to add another participant? *

Yes

No

Second Participant Information

First Name: *

Last Name: *

Date of Birth: *

Home Address

City

State/Province

Zip/Postal

Diagnosis: *

Allergy: *

Reaction:

Hospitalization #: *

Physician's Name: *

Physician's Phone Number:

School Name: *

Teacher: *

Name of Autism Centre Clinician/Social Worker:

Ethnic Background: (must choose one from below) *

Parent / Guardian Information

First Name: *

Last Name: *

Phone number - Cell: *

Phone number – Work:

Phone number – Home:

Email: *

Home Address: *

Home Address:

City

Province

Postal

Please ensure you can be reached during the day on at least one of the above numbers.

Second Parent / Guardian Information

First Name:

Last Name:

Phone number - Cell:

Phone number – Work:

Phone number – Home:

Email:

Home Address:

City

Province

Postal

Please ensure you can be reached during the day on at least one of the above numbers.

Would you like to add another Parent/Guardian? *

Yes

No

Additional Parent / Guardian Information

First Name:

Last Name:

Phone number - Cell:

Phone number – Work:

Phone number – Home:

Email:

Home Address:

City

Province

Postal

Please ensure you can be reached during the day on at least one of the above numbers.

Add Another Parent/Guardian Remove

Emergency Information

Emergency Contact: *

Phone number - best reached at: *

Relationship to Participant: *

Method of Transportation *(must choose one from below)

Method of Transportation: *

Parent/Relative pick-up/drop-off

Paratransit

Taxi

Regina Transit

Preferred Program Session

Please select one only *

Session 1- Monday, July 10- Friday, July 21 ($600) Recurring Activity: Improv | Additional Theme: Cultural Ties

Session 2- Monday, July 24- Friday, August 4 ($600) Recurring Activity: Fieldhouse | Additional Theme: Fun with Food

Session 3- Tuesday, August 8 - Friday, August 18 ($540) Recurring Activity: Swimming | Additional Theme: Hobby-Based Crafts

If your preferred session is full, are you available for the other session? *

Yes

No

If yes, select all sessions you are available and willing to register for: (must choose 0-2 options) *

Session 1- Monday, July 10- Friday, July 21 ($600) Recurring Activity: Improv | Additional Theme: Cultural Ties

Session 2- Monday, July 24- Friday, August 4 ($600) Recurring Activity: Fieldhouse | Additional Theme: Fun with Food

Session 3- Tuesday, August 8 - Friday, August 18 ($540) Recurring Activity: Swimming | Additional Theme: Hobby-Based Crafts

If additional sessions are available, I would like the opportunity to register for more than one session: *

Yes

No

How do you plan to pay for Summer Program? (must choose one from below) *

Credit Card

Debit Card at Registration Meeting

CDS Funding (will only qualify for this year if you have already applied)

Payment Plan through ARC

Cheque

OtherOther

Terms and Conditions

I agree and accept the below terms and conditions:

All fees, or an agreed upon payment plan, are due prior to June 23, 2023.

Participants who cancel their registration 14 days or more from the start of the program will receive a full refund. If less than 14 days’ notice is given, a 50% refund will be issued.

In the event the Autism Resource Centre needs to cancel a program, registration fee refunds will be provided on a pro-rated basis. Any supply or material fees for the program will not be included in the refund.

Once fees have been paid, a non-refundable $50 administrative fee is applied if a session is dropped and/or full withdrawal from the program occurs.
Registrations submitted between 10-10:30 AM on April 22^nd will be placed in a random queue for weeks. Registrations received after 10:30 will be reviewed in order of submission.

Program dates will be confirmed at your final registration meeting. Program waivers must be submitted at time of payment/before the program start date.

Transportation for all participants to/from the camp must be arranged by the family/caregivers.

I give the Autism Resource Centre permission to contact CDS regarding the 2023 Summer Program. Information exchanged will be limited to eligibility for funding.

I agree to the Terms & Conditions: *

I agree and accept the above terms and conditions: *

I agree

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