ErinoakKids - Summer Programs Clinical 2025

Clinician First and Last Name*

Password Provided by Clinician*

Participants First Name*

Participants Last Name*

Participants Date of Birth*

Parent/Guardian First and Last Name*

Parent/Guardian Email*

Parent/Guardian Preferred Phone*

Parent/Guardian Alternate Phone

Address*

City*

Postal Code*

Important Note, Please Read*

I Agree

The activities listed below are available for clients currently receiving services at ErinoakKids. Since these are therapeutic programs, please be sure that the participant meets all of the indicated requirements for that activity before registering. Enrolment is limited. You may also be asked to provide a support person. Please select your first choice program. If interested and eligible for more than one program, indicate your second and third choice.

FIRST CHOICE*

SECOND CHOICE

THIRD CHOICE

Does the participant require 1:1 assistance required to attend the program?*

Yes No

Has the participant engaged in group settings before?*

Yes No

Does the participant use a mobility device?*

Yes No

Please describe any support the participant may need to safely and successfully attend the program

Is there anything else we should know about the participant?

Consent*

I Consent

This request is being submitted with the knowledge and consent of named parents/legal guardians. By providing the above contact information, you consent to receiving information about new service offerings, fundraising initiatives and free events offered at ErinoakKids by email, post, SMS/Text and other electronic means. ErinoakKids will always treat your personal details with the utmost care and will not share or sell your personal information. You may unsubscribe from receiving communications from ErinoakKids at any time. We are committed to keeping your information safe and confidential. We follow the rules set out in law about collecting, using and disclosing your personal information. For more information, please review our privacy policies publicly posted at https://www.erinoakkids.ca/privacy.