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Summer 2021 Child Care Plan

  1. Is medication needed?*
  2. Are there any other concerns or issues regarding your child that you feel we should be aware of?

  3. Consent*

    By checking this box I consent to a City of Coquitlam employee arranging medical attention should there be an emergency situation while my child is participating in camp.

  4. Freedom of Information and Protection of Privacy Act

    By submitting this form, you are consenting to the collection, storage, use and disclosure of your personal information (and that of your child). The City has authority to collect, use and disclosure your information for the purposes of the City’s recreation programs in accordance with Section 26(c), 33.2(a) and 32(a) of the Freedom of Information and Protection of Privacy Act. Your personal information will be disclosed to a third-party service provider (i.e. website host Civic Plus) located in Canada for the purpose of processing your request. Should you have any questions or concerns about the collection of your personal information please call Debbie Clavelle, Community Recreation Manager, at 604-927-6966.

  5. Leave This Blank:

  6. This field is not part of the form submission.