Summer Camp Detailed Registration Form

Camp Spark Registration - 2015
Participant Information
Participant's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Health Information
Health Card No.
Family Doctor
Phone Number
Consent
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Are there any conditions which would prevent your child from taking part in camp activities?
Photo Permission
Camp T-Shirt Order
*Included in the fee for camp.
Additional Camp Spark Merchandise
Method of Payment
Please enclose your payment in full. Cheques should be made payable to Devan Ballagh

Pre-registration (before July 1, 2015)

One child: $200

Two children: $340

After July 1, 2015

One child: $220

Two children: $374
Please note that payment, in full, must be recieved by August 10, 2015.

When payment has been recieved, you will recieve an electronic invoice.
Please select method of payment
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Camp Spark during the selected camp. In exchange for the acceptance of said child’s candidacy by Camp Spark, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Camp Spark and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

Camp Spark Registration - 2015

Health Information

Method of Payment