2015 Registration Form www.campmedley.ca [email protected] REGISTER ONLINE EARLY TO ENSURE A PLACE IN THE CAMP OF YOUR CHOICE ! We encourage you to register online. It’s fast, easy and ensures your camper a spot in camp without delay! General Information—PLEASE PRINT NOTE: This form MUST be completed by the parent or legal guardian of the camper. Please use a separate form for EACH camper that you are registering and mail to the address on the right. Camper’s Name ___________________________________ Male Female Date of Birth _____(m)/_____(d)/_____(y) Age ______ (as of Dec 31, 2015) Parent/Guardian _________________________________________ Mailing Address_________________________________________ City _______________________ Province __________Postal Code __________ E-Parent’s Mail ________________________________ Home # ____________ Work/Cell # _______________ CHOICE OF CAMP Welcome to Camp Girls & Boys 1 Junior Teen 1 Leadership Challenge Girls & Boys 2 Girls Junior Teen 2 Boys Adventure Girls & Boys 3 Junior Teen 3 Senior Teen Family Camp LIT 1 LIT 2 Before June 1: Camp Medley Registrar c/o Ann Pinnell 331 Elmwood Drive Suite 4-824 Moncton, NB E1A 7Y1 After June 1: Camp Medley 168 Gunter Hill Road Upper Gagetown, NB E5M 1N7 AGE DATE COST 7-9 June 28-July1 $200 8-11 June 28-July 3 $300 (One discount per registration and excludes Family Camp) 12-14 July 5-10 $300 Multi-camp 14-16 July 5-10 $300 8-11 July 12-17 $300 1st camp— $300, 2nd camp— $200 8-11 July 19-24 $300 12-14 July 26-31 12-14 July 26-31 $300 $300 8-11 August 2-7 $300 12-14 August 9-14 $300 15-17 August 16-21 CHOICE OF CABIN MATE All ages June 26-28 $300 $150 family of 4 1) __________________________ 16+ July 5-17 $300 16+ July 26–August 7 $300 2) _________________________ We will try to accommodate but cannot guarantee All prices include registration, tucke and HST. DISCOUNTS Family (Immediate Family) 1st child— $300, 2nd child— $200, 3rd child or more— contact office for additional discount PAYMENT cheque/money order Credit Card ___________________________ Expiry Date _______________ Total Cost _____________ Payment __________ (min$60) Signature __________________________________ The balance is payable on or before the first day of camp. If a camper withdraws prior to the opening of camp, the portion of the fee paid over $60 will be refunded. Refunds are not possible on or following the first day of the camp session. Camp Medley Medical and Release Form 2015 Camper’s Full Name ________________________________________________________________ Male Female Age ________________ Weight _____________ Is your child covered by provincial medical insurance? Yes No If YES, Medicare #: ___________________________________ Expiry Date:________________________ If NO, what form of coverage is available for the camper? ________________________________ NOTE: It is the responsibility of the parent/guardian to ensure proper coverage. Does your child have any physical, mental, or emotional weakness or disabilities that the camp should know about? i.e. If your child has ADD, ADHD, asthma, allergies, etc. PLEASE TELL US! ** Yes No ___________________________________________________ Does your child have any life threatening allergies?** Yes No _____________________________________________ Will medications be required at camp?** Yes No (If Yes please list below) Can Tylenol be administered if necessary? Yes No Can Ibuprofen (Advil) be administered if necessary? Yes No Does your child have any allergies to food or drugs?** Yes No _____________________________________________________ Is your child affected by any of the following: (please circle): eating disorder, bed wetting, heart conditions, sleepwalking, diabetes, fainting spells, seizures, headaches, other** _______________________________________________________________________________ Tetanus shot recently or last 10 years: Yes No Not sure **NOTE: If YES - Please give any details and helpful information on a separate sheet if you do not have enough room on the lines above. ALL MEDICATIONS MUST BE GIVEN TO THE CAMP PERSONNEL UPON ARRIVAL AND MUST COME IN ORIGINAL PACKAGE. ALL MEDICATIONS WILL BE DISPENSED BY AUTHORIZED STAFF. No Camper is to keep any medications in Camper’s Cabin. Please list any medications your child is taking and include detailed information on how to administer that medication. Medication Dosage Times Days Emergency Information Family Physician: _________________________________________________Phone: _______________________________ Parent/Guardian Name: ______________________________________ Home Phone: ____________________ Work Phone: ________________ext. ______ Cell Phone: __________________________ Emergency Contact’s Name: _________________________________ Relationship to Camper: ___________________________ Home Phone: ______________________Work Phone: _________________ ext. _________Cell Phone: _____________________ I believe my child is medically and physically capable to attend Camp Medley. I will not bring my child to Camp if he/she has a contagious or communicable disease. I expect the Camp Director or Assistant Camp Director or Camp Nurse to try to make contact with myself or alternative Secondary Decision Maker in case of a medical emergency involving my child. I grant the Camp Medley Director or Assistant Director to seek necessary medical attention for my child at a Hospital emergency department and or Medical Clinic depending of need of the incident. I expect that the personnel of Camp Medley will take every precaution to ensure the good welfare and protection of my child named in this medical release form. I understand the information given in this form will be used only as necessary for the normal operation of Camp Medley. I hereby release Camp Medley , its Director, Assistant Director, all staff members, Board of Directors and any and all off-site employees from any and all liability in the event that the said named child on this Medical Release Form is involved in an accident or other misfortune. No camper will be accepted without a completed and signed medical and release form. Signature of Parent/Guardian: __________________________________________Date: __________________________________
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