Camp Elements Sport
DAYCAMP (Grades 1-6 in September) Registration Form
AUGUST 15-19, 2016
Registration Fee: $110 early bird ($125 after May 1)
Camper Information
Name: ____________Last
First__________________
Gender:
M
F
Mailing Address: __________________________________________________________________________________
City: _______________________________
Province: ________
Date of Birth: ____Year___|___Month___|___Day___ Age: __________
Postal Code: ____________________
Current Grade: __________________
Camper’s Email: _________(If applicable) __________________ Home Church: _______(If applicable)______________
School Camper Attends: _____________________________________________________________________________
How did you hear about Camp Elements?
Church
Friend/Family
Advertisement
Parent/Guardian Name(s): _________________________________________________
Other: ________________
Authorized to pick-up child
Home Number: (____)________________ Day Phone: (____)_________________ Cell: (____)_____________________
Email: ___________________________________________________________________________________________
Emergency Contact: (If Parent/Guardian cannot be reached) Name: _________________________________________
Phone: (____)______________ Relationship to Camper: _________________________
Authorized to pick-up child
Authorized Pick-Up: (list the names of those you authorize to pick-up your child from camp. Picture I.D. is required upon
pick-up)
Name: ____________________________________ Telephone: ___________________________
Name: ____________________________________ Telephone: ___________________________
Medical Information
Health Card #: ____________________________________ Version Code: ____________________________________
Does the above named camper have any allergies, will be taking any medications while at camp, or have any physical,
mental or other condition or weakness that might hinder normal participation in camp activities?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Camp Selection
Check off camp choices
✓
At Camp Elements Sport kids can choose between Soccer, Basketball, Hockey, or “All-Around-Athlete” (a mix of all 3
Sports) and receive coaching and positive instruction to help improve their skills. This camp is open for kids at all different
levels of skill and experience.
Step 1: Select your Sport
Step 2 (optional):
Tuck (Snack Shop)
vBasketball
vSoccer
vHockey
vAll-Around-Athlete
Step 3 (optional): Extended
Hours $5/day (8-9am & 4-5pm)
Monday
v
v
Tuesday
v
v
Wednesday
$5.00
v
$10.00
Thursday
Step 4: Payment
Registration Fee ($110) $
($110 Early Bird/$125 after May 1)
Friday
Tuck $
Extended Hours ($5/day) $
Total Payment: $
Please fill in both sides of this form and return to West
London Alliance Church with complete fees. Registrations may
be mailed to 750 Wonderland Road North London, ON
N6H 4K9. Upon receiving your application, an information
package and receipt will be sent to you!
Make cheques payable to:
West London Alliance Church
Office use only:
Payment Made: $__________
Method:
Cash
Cheque
Date Received: ____________
Cancellation Policy: No refunds will be given after June 1,
2016
Conditions
of Enrollment
1. You have my permission for the above named child to attend Camp Elements and participate in all activities on the property of West London Alliance
Church.
2. The parents/guardians submitting this application are those having legal custody over the child.
3. The Camp Directors reserve the right to dismiss any child who in his/her opinion is a hazard to the safety and rights of others or who appears to have
rejected the reasonable expectations of the camp.
4. The parent or guardian hereby agrees to reimburse the Camp for any property damage caused by the camper.
5. While every precaution shall be taken to ensure the good welfare and protection of the camper, Camp Elements, West London Alliance Church, its
staff and board members, employees and volunteers or facilities outside the church property are hereby released from any and all liability in the
event of any accident, illness or misfortune that may occur to the camper.
6. I hereby authorize Camp Elements personnel to handle any medical problem with my child during his/her stay at camp. After making every
reasonable effort to contact parents/guardians and emergency contacts named in this registration, permission is hereby given to the physician
selected by Camp Directors to provide proper treatment. This may include being removed from the site to a local hospital. The parent or guardian
is responsible for any additional expense that might arise from such a service.
7. There will be no reduction of fees for campers arriving late, leaving early, or expelled through disciplinary action.
8. West London Alliance Church has permission for the reasonable use of camp pictures containing your child’s image in future promotional materials
(brochures, videos, displays).
9. All information collected in this registration will be used only by Camp Elements for the specific purpose of providing an excellent camp experience
for your child.
10. I have read the Camp Elements brochure and application form, have provided true and accurate information and am in full agreement with the
conditions of enrollment.
____________________
Date
_________________________________
Parent/Guardian Signature
______________________________________
Parent/Guardian Name (Please Print)
It is understood that by submitting a camp registration for your son or daughter that you are providing consent for Camp Elements to collect and retain
information necessary for Camp Elements to provide a safe, healthy, fun camp experience for your child and to collect payment for the same.
If you have any questions concerning Camp Elements Registration, please contact Angela at (519) 471-8716 or
at camps@wlachurch.org. See you in the Summer!