2023 ARC Summer Camp Registration Form 2023 ARC Summer Camp Registration Participant Information First Name: * Last Name: * Date of Birth: * Diagnosis: * Health Card Number: * Family Doctor Name: * Family Doctor Number: Name of Autism Centre Clinician/Social Worker: Allergies: * Reaction: School Name: * Teacher: * Classroom Type (must choose one from below) FIAP EFAP DC Mainstream OtherOther Ethnic Background (must choose one from below) * Black Indigenous White Prefer not to say OtherOther Would you like to add another participant? (must choose one from below) * Yes No Second Participant Information First Name: * Last Name: * Date of Birth: * Diagnosis: * Health Card Number: * Family Doctor Name: * Family Doctor Number: Name of Autism Centre Clinician/Social Worker: Child and Youth Clinician name Allergies: * Reaction: School Name: * Teacher: * Classroom Type (must choose one from below) * FIAP EFAP DC Mainstream OtherOther Ethnic Background (must choose one from below) * Black Indigenous White Prefer not to say OtherOther Parent / Guardian Information First Name: * Last Name: * Phone number - Cell * Phone number – Work: Phone number – Home: Email * Address * Address Address Address City City Province Province Postal Postal Parent / Guardian Information First Name: Last Name: Phone number - Cell Phone number – Work: Phone number – Home: Email Address Address Address Address City City Province Province Postal Postal Would you like to add another Parent/Guardian? (must choose one from below) * Yes No Additional Parent / Guardian Information First Name: Last Name: Phone number - Cell Phone number – Work: Phone number – Home: Email Address Address Address Address City City Province Province Postal Postal Add Another Parent/Guardian Remove Emergency Contact Emergency Contact: * Day-time Phone Number: * Relationship to Participant: * Method of Transportation * (must choose One From Below) Method of Transportation * Parent/Relative pick-up/drop-off Paratransit Taxi Preferred Program Weeks How many weeks are you hoping to register your child(ren) for this summer? * Select12345 Please check all weeks you would be willing to have your child attend summer camp. Please note, program dates will be confirmed at your follow up registration meeting. Selecting a week does not guarantee availability. * (must choose from options below and can select all) * Week One: Monday, July 10- Friday, July 14 ($300) Week Two: Monday, July 17- Friday, July 21 ($300) Week Three: Monday, July 24- Friday, July 28 ($300) Week Four: Monday, July 31- Friday, August 4 ($300) Week Five: Tuesday, August 8- Friday, August 11 ($240) Week Six: Monday, August 14- Friday, August 18 ($300) Week Seven: Monday, August 21- Thursday, August 24 ($240) If additional weeks are available, I would like the opportunity to register for more than 5 weeks (must choose one from below) * 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 Daytime contact who is available on April 21st to set-up Registration Meeting for early May: Name: * Phone Number: * 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. Once fees have been paid, a non-refundable $50 administrative fee applies if week(s) are dropped and/or full withdrawal from the program occurs. 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. Registrations submitted between 10-10:30 AM on April 15th, 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 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 Captcha If you are human, leave this field blank. Submit
