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: __________________________________