Clear Entire Form

Clear Entire Form
PLEASE PRINT CLEARLY
CAMPER INFORMATION ………………….…………………………..…………….……………….........................………………..
(Last Name)
(Given name commonly used)
Student’s Birthday …..…… / …...…… / …..……
Day
Month
Year
Gender:
Male
Female
School………...………………………………………………………………………..….…... Grade Level………………….
PARENT INFORMATION
Please identify parent(s) or guardian(s). List Primary Contact Person first…
Primary Contact Person: ….………...……………………………
Parent/Guardian 1
Relationship:
Alternate Contact Person:…………...……………………………
(Last Name / First Name)
Parent/Guardian 2
…………...………………………………
Relationship:
(Last Name / First Name)
…………...………………………………
Daytime Contact Telephone Number…………………………….….
Daytime Contact Telephone Number…………………………….….
Evening Contact Telephone Number…………………………….….
Evening Contact Telephone Number…………………………….….
E-Mail ………………….……...………………………………………
E-Mail ………………….……...………………………………………
CONTACT INFORMATION
Home Street Address …………………………………………………..…….……………………………………..……………………………
City …………………………………………………………………
Province or State ………………………………………...……….……
Country …………………………………………………………....
Postal/Zip Code …………………………………………………………
Additional Emergency Contact Name: ………………..……………..…
Telephone.: (Day)…………………..………..
Relationship to Student: ………………………………………
(Eve)…………………..………..
(Cell)…………………..………..
Fees are non-refundable after March 01, 2015.
 We would be interested in using a charter bus to or from Toronto. Please keep us in mind, if there are sufficient numbers to warrant.
COMPLETE APPLICATION
Please fax, mail or e-mail BOTH SIDES of this Application Form to:
1844 Ravenscliffe Rd. Huntsville, ON Canada P1H 2N2
Phone: 705-789-5612
Fax: 705-789-6624
E-mail: [email protected]
Camper Fee March Break April 15-20, 2015
$610.00
HST (13%)
$79.30
You may wish to add a donation to Jack Pearse Memorial Campership Fund*:
$ 0.00
GRAND TOTAL
*Jack Pearse Memorial Campership Fund
The Jack Pearse Memorial Campership Fund has been set up by
our Tawingo Alumni Circle Committee to accept donations and
send campers to Camp who would gain from a summer camp
experience but whose families do not have the resources available
to provide it themselves. The Tawingo Alumni Circle commits to
supporting a child through his or her entire career at Camp, thereby ensuring the best possible benefit for the child as he or she
grows and develops. Inquiries and donations are always welcome.
Camp Tawingo - 1844 Ravenscliffe Road, Huntsville ON P1H 2N2
Ph 705 789 5612 Fx 705 789 6624
[email protected] tawingo.net
$ 689.30
Please return this form with Full Payment:
$ 689.30
Amount $..................
 Visa Card
 MasterCard  Cheque/Money Order payable to CAMP TAWINGO
Number ………………………………………………………………………………………………………….…
Expiry Date
…………………………
Name on Card ……………………………………………….
Office Use: Amt:____________ Date: ____________ Rcpt #: ____________ Ack:____________
Clear Entire Form
CAMPER INFORMATION AND MEDICAL RECORD
HEALTH INFORMATION
CAMPER NAME: ……………………………………….…..……………………………………… GENDER:
(Last Name)
(First Name)
Male
Female
HOME ADDRESS: …………………………………………………….………………………………
CITY: ……………………………...
PROV./STATE: …………………………………. POSTAL/ZIP CODE: …………………………
COUNTRY: ……………….……..
HEALTH CARD NUMBER (incl. 2 letters that follow, if applicable): ….…………..………………….………………… LETTERS:……..
VALID:
.…….. ..…….. ...…...
Year Month Day
to ...…… ….......
Year Month
.…….
Day
(if applicable)
Family Doctor’s Name: …………………………………………………
BIRTHDATE: ..……. .…..…… ...….....
Year
Month
Day
Doctor’s Tel.: …….…....…………………..
Allergies – Foods (specify): ………………………………………………………………………….………………………………………
Drugs (specify): ………………………………………………………………………………………………..……………......
Other (i.e. Bee Stings): ………………………………………………………………………………….…...........………..….
My child carries an Epipen
No
Yes for the following allergy: ……………………………………....................
Note: All dietary concerns, food restrictions and intolerances must be listed with us prior to MARCH 01 2015. All information regarding special dietary needs will be shared with the kitchen staff. (Please note that Camp Tawingo menus do not
cater to likes or dislikes. We provide a balanced and varied menu that often includes red meat, poultry, and fish.)
 Vegetarian (No red meat)
 Celiac Disease
 Vegetarian (No meat)
 Lactose Intolerance
 Vegan (No animal product)
 No Pork
Expand upon the implications of any of these restrictions, if applicable...
…………………………………………………………………………………………………………………………………………………
Does your child have any significant medical conditions, physical limitations, or other concerns which might affect a stay at Camp?
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
Is your child receiving regular medication(s)?
Medication Name
 Yes
Dosage
 No
Administration Time (s)
Reason for Taking
…………………………………..
……………………………
……………………………….
…………………………………
…………………………………..
……………………………
……………………………….
…………………………………
Date of last Tetanus Shot (DPTP Shot on Immunization Card) MANDATORY (DD/MM/YY) ………………..………….…
To the best of my knowledge, this child does not have a communicable disease, and is physically able to participate in all Camp activities except
as indicated above.
All medical problems or conditions requiring ongoing medical supervision or care have been fully noted.
I give permission for this health information to be shared with the appropriate Camp staff and outside Medical Personnel as necessary.
I understand that I will be notified if extended or emergency care has been provided by Camp, or following assessment or treatment by a local
physician.
I agree to notify the Camp in writing if any changes occur in my child’s health status, medications, or family status
between now and the start of the Camp session.
I understand that further agreement to all matters outlined in Final Instructions sent at a later date is required
MY SIGNATURE BELOW INDICATES ALL INFORMATION ON THIS APPLICATION FORM IS COMPLETE AND ACCURATE.
…………………………………………………………………
Signature of Parent/Guardian
…………………………………….
Date