CAMPERSHIP APPLICATION – to be completed by parent/guardian Phone: (416) 948 5437 E-mail: [email protected] Please complete one application per child Name of camper _______________________________________ Gender M □ F □ Age Names of parent(s) or guardians(s) Relationship to the camper ____________________________________________________________________ Address ___________________________________________________________________________________ Home telephone (____)____________ Business telephone (____)______________E-mail: Name of camp your camper wishes to attend: CAMPER INFORMATION Personal information contained in this form will be used to select campers to be funded by Kids in Camp. The privacy of the information is protected and will not be used for any other purpose. How many adults live with this camper? _______ How many children live in the same home? Is there a parent/guardian outside the home who is involved with this camper? _______ Yes □ No □ If yes, please state their relationship to the camper: ______________________________________________ Does the parent/guardian outside the home provide any financial support to the camper? Yes □ No □ Annual family income from all sources (incl. adult(s) outside home who provide financial support) $____________ (Confirmation of income(s) required by Notice of Assessment.) Is this camper being sponsored by another agency, public health, charitable organization or Children’s Aid Society to attend camp? Yes □ No □ Have you applied for other financial assistance for this camper? Yes □ No □ Has the camper attended camp before? Yes □ No □ If yes, where? _____________________________ Has the camper received financial assistance for camp in the past? Yes □ No □ If yes, from whom/where? ____________________ Is the camper attending an additional camp this summer? Yes □ No □ If yes, will he/she receive financial assistance? Yes □ No □ Are there any additional circumstances that may be of importance regarding this application? (additional information may be attached) I certify that all information above and/or attached is true and accurate. I understand that my camper may have a photograph taken while at camp and may be asked to contribute in some way to the charity’s efforts to raise funds (e.g. speak or write about his/her experience at camp for a fundraising event). My camper will also be asked to complete a camper report form before leaving camp, with staff assistance. I agree to indemnify and hold harmless Kids in Camp and its officers, directors, employees and volunteers from and against any and all losses, claims, demands, causes of action or litigation, including all costs thereof as a result of camp operations and activities. Parent/Guardian’s name (print): ________________________________________________________________ Signature: Date: Please send this completed application to the camp supporting your application. The camp will forward the application to Kids in Camp. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. 12/05/13 – KICCampershipApp-Parents