Municipality of Arran-Elderslie              
  Box 70, Chesley, ON N0G 1L0   Fax to:  363-2203        
  Phone 519-363-3039                  
  Chesley Pool Child Information Record          
                       
Registrations after May 31,2008 will be subject to a 25% penalty.        
Cancellations must be made 31 days in advance of the start of the class in order to receive a refund.
Please complete a separate form for each child registered.        
  Child's Name:               Location □ Chesley
                      □ Tara  
  □ Male     □ Female                
Summer Swim Lessons 2008  - Please check Session          
  □ Session 1    July 7-18           □ Session 3    August 4-15
  □ Session 2    July 21 - August 1           □ Session 4    August 18-29
Alternate Contact (if parents not available)              
Name:               Phone:    
                       
  Parent Information
Parents Name/s: Picked up by:  ONLY THE PEOPLE LISTED ON THIS
Mailing Address: FORM CAN PICKUP YOUR CHILD(REN) Any changes
  must be communicated in writing to pool staff.
Phone number - home:  
Phone number - work:  
Phone number - cell:  
Emergency Contact: Other family members enrolled:    
Phone Number:  
Relationship to child:  
  Photographs
Photographs may be taken by the newspaper or staff and utilized for promotional purposes.  
  Check here if you DO NOT want your child photographed. □        
  Registration - Please select 1st and 2nd choice - registration will be confirmed by phone
My childs swimming ability is as follows - (please check one)  Comfortable in……    
  □ shallow end only   □ deep water   □ Last swim level completed    
Registration for 2008 Chosen times                
Ist Choice     Level:     Session:   Time:    
2nd Choice     Level:     Session:   Time:    
  Allergies
Does your child have any allergies?                
If YES please explain:                  
                       
                       
  Medication
Is your child on any medication (prescription or non-prescription)    Health Card # ________________________
Name of medication and reason for taking it:              
Dosage and time to be taken:                
Does your child require assistance taking this medication?          
Camp staff have permission to assist my child?            
  Other Important information regarding the registrant
Examples include behavioral issues, unique circumstances etc.        
                       
                       
                       
Parent/Guardian Name: Date:     Signature: