Camp Maple Leaf Camper Registration Form

Camper Profile

First NameMiddle NameLast NameBirthdate (dd/mm/yy)

Gender School/GradeT-Shirt Size Camper Email

Choose from: Youth S, M, L; Adult S, M, L, XL

Health Card Doctor’s Name Doctor’s Phone

Who does the Camper live with and what is the address?

Parent/Custodian First NameParent/Custodian Last NameRelationship to Camper

Street Address Line 1Street Address Line 2

City/TownProvincePostal Code

Daytime PhoneEvening PhoneParent/Custodian Email

Who should we contact in an emergency if the person listed above under Parent/Custodian is not available?

Emergency Contact First NameEmergency Contact Last NameEmergency Contact Relationship to Camper

Daytime PhoneEvening PhoneEmergency Contact Email

Sponsoring Organization – This means the name of the agency providing the Referral Code

Organization CodeWorker or Contact Person First NameWorker or Contact Person Last Name

Worker/ Contact Person EmailWorker/Contact Person PhoneWorker/Contact Person Cell

Transportation

When the Camper is going to Camp, they will be dropped offat the Bus Stop in:

OR

For the safety of your Camper it is important that we know who will bedropping off the Camper at the bus/camp.

First and Last NameCell Phone NumberHome Phone Number

When the Camper is coming home from Camp, they will be picked up at the Bus Stop in:

OR

For the safety of your Camper it is important that we know who will bepicking up the Camper at the bus/camp.

First and Last NameCell Phone Number Home Phone Number

From time to time campers have been left at Camp Maple Leaf or the bus stop waiting for their ride with no way to get home. Please be aware that after 60 minutes (1 hour)we have a legal duty to report the Camper as abandoned to the local Children’s Aid Society.

Changes to the Registration or Transportation information require a Camper Change Form.

Please go to and click on the CAMP OFFICE tab

Downloadthis form and return as instructed.

PLEASE NOTE:if you answer yesto dietary needs, allergies or taking medication, you will be required to fill out a health history form available for download. Campers will not be allowed to attend camp without a properly completed form submitted 14 days prior to the camping session. there will be no exceptions due to safety concerns.

Dietary needs

special diet needs may be religious based (no pork), health requirement (gluten free) or specific diet (vegetarian). If camper has a restricted diet, complete health history form and specify in dietary needs section.

Allergies

Medication

Is the Camper having any specific concern/fear/anxiety about attending Camp Maple Leaf

If yes, please explain

Do you have any specific concern/fear/anxiety about the Camper attending Camp Maple Leaf.

If yes, please explain

Registration

Summer Camp Sessions: Ages 8 to 13 (as of December 31, 2014)

Campers arrive at Camp on Monday and depart on Saturday

Session 1: June 30 – July 5Session 2: July 7– 12Session 3: July 14 – 19Session 4: July 21 – July 26

Session 5: July 28 – August 2Session 6: August 4– 9Session 7: August 11 – 16Session 8: August 18 – 23

Please enter Session #: First Choice Second Choice

Summer Camp Sessions: Leaders in Training Ages 14 to 15 (As of December 31, 2014)

Leaders in Training Application Formmust be submitted and approvedbefore Registration. Once approved, you will be provided with a Referral Code to be used during registration.

LIT Sessions:

Counsellor in Training Ages 16 to 17 (As of December 31, 2014)

Must be submitted before May 1, 2014. They are available on

Who will be covering the cost of the Registration Fee? ($750/week/camper),

(Please note that fees paid by Parent/Guardian must be received before the start of the camp session)

REFUNDS

  • Norefunds areavailablewithouta completed Camper Change Request Form.
  • Full refund only if the requestis received 14 days or more prior to the start of camp session
  • 50%refund if the requestis submitted less than 14 days priorto session start
  • Norefund if theCamper doesnot attend camp without proper cancellation notification.

Declarations

The Parent/Guardian will assume full responsibility for any extra expenses required for the treatment of the Camper that are not covered by the Ontario Health Insurance or the Equivalent Health Insurance.

While every precaution shall be taken to ensure the welfare and protection of Campers, Camp Maple Leaf Incorporated, Banyan Community Services Inc., its employees, and volunteers are hereby released from any or all liability in the event of injury, illness, or misfortune including loss of property to the camper.

I authorize that the electronic entry of my name below is equivalent to a hand printed signature on a paper document.

Signature of Custodial Parent/Guardian Date Relationship to Camper

*HEALTH HISTORY FORM ATTACHED AS SEPARATE FORM

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