PD Day Camp (Conseil scolaire Viamonde)

How many people are you registering? *

Child Registration Details

Child's first name *

Child's last name *

Child's pronouns

she/her/hers

he/him/his

they/their/theirs

Child's birth date *

Child's age at start of class *

Please detail any health or emotional concerns, including allergies, that the Gallery should be aware of. Will your child be bringing any medication to the Gallery? Do they carry an EpiPen?

Medical notes *

Please provide the parent/guardian's name

Parent/guardian 1 name *

Parent/guardian 1 telephone *

Please provide the parent/guardian's name

Parent/guardian 2 name *

Please provide the parent/guardian's telephone number

Parent/guardian 2 telephone *

Email *

Emergency contact name in the event that parent(s)/guardian(s) cannot be reached.

Emergency contact name *

Emergency contact (telephone number) in the event that parent(s)/guardian(s) cannot be reached

Emergency contact telephone *

Additional pick-up names *

If your child is 12 -13, please indicate if they have permission to leave on their own. Children with permission to sign themselves out will only be able to do so at 4:00 p.m.

Leave on own permissions *

I give my child permission to leave on their own at the end of class

I do not give permission for my child to leave on their own

Sibling sign-out *

I authorize my child can sign-out their younger sibling

I do not authorize sibling sign-out

I hereby authorize any images of myself to be displayed on the Kitchener-Waterloo Art Gallery Website and social media platforms; and to be used for external media purposes including marketing campaigns and promoting our recreational programs.

Photo Permission *

How did you hear about this program?

Referral *

If there is any additional information you would like to share about your child, to better support them during their time at class please include below.

Additional information

Event Fee(s)

If you have a discount code, enter it here

Please select event fees related to the child information on this page

6 - 13 years *

6 - 13 years - $ 60.00

Extended Aftercare

Aftercare - 1 Child - $ 15.00

Total for this participant

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *