1. automotive and vehicles
2. campers and rvs

Pine Orchard Day Camp – Superheroes
2015 Registration Form
Pine Orchard Camp 4088
Vivian Rd, Cedar Valley, ON L0G 1E0
CHILD’S NAME(S)
Date of Birth
________________________________
d___/m___/Y______
________________________________
d___/m___/Y______
________________________________
d___/m___/Y______
HOME ADDRESS (street) ___________________________
(town)___________________(postal code)_____________
Phone – hm (_____)____________ wk (_____)__________
Parent’s Email: __________________________________
Emergency Contact Name and Phone #:
_____________________________ (_____)___________
Allergies / Medications Required:__________________________
Please attach a photocopy of each child’s Health Card.
Home Church __________________________________
Please Note: There are 2 weeks of camp. Please indicate for
which week you are applying. [ ] June 29 – July 3
[ ] July 6 – 10
PARENT/GUARDIAN ________________________ (please print)
=============================================================
1 Week Fees: $75 Per Child
$200 Family Rate 3 children or more - same family
SIGNATURES
Conduct and Modesty
As a Christian organization Pine Orchard Camp maintains a high standard of
conduct. It is expected that all campers will conduct themselves in a Christian
manner, consistent with Biblical principles.
Modesty is the key for clothing at Pine Orchard Camp. Clothing that is tight,
revealing or that boasts inappropriate writing or designs is not permitted at
camp.
Girls: Low necklines, short shorts and mini skirts are not considered modest
attire. Swimwear should be a modest, one-piece suit.
Boys: Modest swimwear, boxer style trunks.
Pine Orchard Camp reserves the right to require anyone to change his or her
outfit if, in the estimation of the staff, it does not comply with these standards.
Do not let this be an issue that affects your week at camp
I have read the above and discussed the same with my children. We agree to
comply with the Conduct and Modesty regulations while at camp and agree to
co-operate fully with the Director and Camp Officers and staff at all times.
Parent/Guardian Signature: _________________________________________
I give permission for the use of photographs audio and video footage, which
includes my child for the purpose of camp publicity.
Parent/Guardian Signature: _________________________________________
While every precaution is taken to ensure the welfare and
protection of each child, no activity is completely risk-free. I hereby
release Pine Orchard Camp, its Directors, staff, employees and facilities
from any and all liability in the event of any accident or misfortune that
may occur to the applicant(s). I also hereby grant my permission for the
applicants(s) to participate in all programmed activities.
In signing the registration application, the parent or guardian
certifies that the applicant(s) is amenable to necessary discipline.
________________________________
Signature of Parent or Guardian
CHEQUE OR MONEY ORDER:
For office use:
___________________
Date
Payable to “Pine Orchard Camp”
(post-dated June 12, 2015) Note: Cheques will not be cashed until after June 12, 2015
Payment
Check [√] when paid
$75 / Child [ ] [ ] [ ] Total $ ____________
MAIL TO: Joe Schaefer PO Box 1354 Campbellford, ON K0L 1L0
You will be contacted by email to confirm the reception of your application.