Work Shop and Camp Registration Form

Registration is only complete when payment is received through the online payment page

Parent's Name *
Parent's Name
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Address
Address
Second Parent / Guardian
Name second parent / guardian
Name second parent / guardian
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Address
Address
optional
Student Info
Student Name *
Student Name
Student Address
Student Address
optional
Student Phone
Student Phone
Birth Date
Birth Date
Medical
optional
Doctor's Name
Doctor's Name
optional
Doctor's Phone
Doctor's Phone
optional
optional
optional
Note: if the camper is on ANY medication, a medication form will have to be filled out before attendance. Email: dgoodfellow@gmail.com to request a form.
Emergency Contact
Emergency Contact
Emergency Contact
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Please share any additional information that you feel we should know in the space below
Additional adult with permission to pick up student
Additional adult with permission to pick up student
Programme Selection
Disclaimer
Waiver of Liability *
Waiver of Liability * I, the undersigned guardian, hereby release and forever discharge the Brick Works Academy and Emote Media Inc. and its respective officers, employees, agents and program supporter/sponsors from and against all claims, actions, costs, damages and expenses with respect to damage and/or bodily injury to my child or property as a result of his or her participation in the said “Brick Works Academy Camp”. I understand that Brick Works Academy Camp has a violence-free, peanut-free, inclusion and computer-use policy to ensure the safety of all participants. Any behavioural misconduct will result in immediate removal from this program, with no money refunded. Having read and understood the indemnification and release form in its entirety, I declare that I hereby agree to be bound by the terms and conditions. Participants in Brick Works Academy may have their photos captured and displayed for the purpose of informing parents of the days activities and their child's progress. These photos may also be used in marketing material promoting Brick Works Academy Camps. Understanding the terms and conditions of this indemnification and release, I give my consent for the registrant to participate.

Registration is only complete when Payment is received through the online payment page.