Camper Registration (Word)

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CAMPER APPLICATION FOR ASD SUMMER DAY CAMP 2015
Registration Information: Please complete and submit to register interest – An intake meeting will be
necessary if new to Children at Risk programs or has not attended since 2013.
Submission of Application form to Children at Risk:
By mail at: Children at Risk, 235 Donald Street, Suite 209, Ottawa, ON, K1K 1N1
By email to: [email protected]
By Fax: 613-741-5530
Camp Location: Lester B. Pearson Catholic High School, 2072 Jasmine Cres.(at Ogilvy), East-Central Ottawa.
Camp Fees: $375 for 5-day weeks, $300 for the 4-day week (August 4-7)
*NEW* - Only 2 weeks can be offered at above subsidized price – additional weeks may be offered
(contingent upon camper’s needs, staff availability & funding) at $500/week ($400 for 4-day week)
Ages: 4-20+ Subject to responses received, as only 50 participants per week.
PLEASE SEND A HEAD SHOT PICTURE OF YOUR CHILD WITH APPLICATION!
How many weeks of Camp are you looking for in total? Number: ______
State preference of weeks i.e 1,2 ,3 or √ if no preference….availability dependent on demand
July 13-17
August 4-7 (short week)
July 20-24
August 10-14
July 27-31
Camper Information:
Name:
Date of Birth (D/M/Y):
Address:
City:
School:
Diagnosis
Medications? YES/NO
Other Medical or physical considerations
Gender:
Age:
Postal Code:
Grade Completed:
Parent/Guardian Information:
Contact #1:
Name:
Address: (if different)
City:
Phone number:
Email:
Contact #2:
Name:
Address: (if different)
City:
Phone number:
Email:
For Office use only:
Confirmed Weeks of Camp:
Relationship:
Postal Code:
Work/Cell Phone:
Relationship:
Postal Code:
Work/Cell Phone:
Week 1 Week 2  Week 3 Week 4  Week 5 
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