Secret Agent Society Social Skills- Spring Camp 2024 Registration Form

Does your child have access to a device that they could use for the duration of the camp ie. tablet or laptop *

Yes No

Can your child read at a Grade 3 level or above? *

Yes No Not sure

Does your child receive any additional assistance at school? i.e Learning Support, on an IEP? *

Yes No Not too sure

Is English your child's first language? *

Yes No

How would you rate how well your child speaks and understands English? *

Very well Well Reasonably well Poorly Very poorly

Has your child been diagnosed with a mental health condition or psychological disorder, such as an Anxiety Disorder, Attention Deficit Hyperactivity Disorder (ADHD) or an Autism Spectrum Disorder? *

Yes No Waiting for a diagnosis, currently under testing

Has your child ever been diagnosed with a learning disability, language disorder or intellectual delay? *

Yes No

Has your child undergone Psych Ed testing in the past 2 years?

Yes No Currently undergoing assessment

Will you be accessing funding to pay for the program? *

Yes, Autism Funding Yes, School Funding No, bill me privately

I give consent for my child to participate in the Secret Agent Society Spring Camp. *

Yes No

Secret Agent Society Social Skills Spring Camp Statement of Agreement:

Medical Release:
I hereby declare that I am the parent or legal guardian of the above-named child and that the information I have given is accurate.

I give my consent, in the event that all reasonable attempts to contact me or designated persons above have been unsuccessful, For West Coast Centre for learning personnel to seek treatment by the position named above, or in the event the preferred practitioner is not available, by another licences person.

I hereby release and discharge West Coast Centre for Learning, it's agents, employees, and officers, from claims, demands, actions, or judgements which the undersigned ever had, now has or may have against West coast Centre for Learning, it successors, or assigned, for all personal injuries or illness, which the child named above may suffer or incur as a result of the actions of West Coast Centre for Learning or in procuring medical treatment.

I certify that the child named above is in good health and free from and communicable disease or illness.

Statement of Understanding:
I have read the program description, policies and information, and procedures of West Coast Centre for Learning Summer Day Camp. I understand and agree with the philosophy and policies; I accept the conditions and terms stated therein. *

I agree I do not agree

I consent to having photographs and work samples of my child/ren used by West Coast Centre for Learning in promotional materal. * *

I agree I do not agree

Secret Agent Society Social Skills- Spring Camp 2024 Registration Form

Secret Agent Society Social Skills- Spring Camp 2024 Registration Form

Parental Consent to Participate in the Program

Thank-you for completing the registration form. A member of our team will be in contact with you shortly to schedule a short intake interview.