Camp GEO! Easter Camp 2015: Registration Form Please fill out a form for each child you are registering. REGISTRATION OPENS: Monday March 2nd, 2015 at 9:00 A.M. REGISTRATION DEADLINE: Friday March 27th, 2015 at 5:00 P.M. Space is limited, so register early! Registrations may be submitted in person, by fax, or e-mail. We accept credit card, cheque, cash or debit. Payment is due when submitting registration. E-mail: firstname.lastname@example.org Telephone: (709) 737-7878 Fax: (709) 737-7889 Registration is NOT complete until you have received a confirmation email. Section 1: Camper InformationCamper's Name* First Last Date Of Birth* Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Age (at time of camp)*78910Grade (at time of camp)*2345Section 2: Parent/Guardian Information (Primary Emergency Contact)Parent/Guardian Name* First Last Parent/Guardian Email* Daytime Phone*Other PhoneAddress (if different than above) Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Section 3: RegistrationPlease check off the dates your child would like to attend camp:* Monday April 6 Tuesday April 7 Wednesday April 8 Thursday April 9 Friday April 10 Section 4: Alternate Emergency Contact (Different from Section 2 Contact)Emergency Contact (if different from above) First Last Emergency Contact Phone (if different from above) Use this as my primary emergency contact Section 5: Medical InformationDoes camper have a medical condition (including allergies)?*YesNoIf yes, please provide further information (type of condition, symptoms, what to do in case of emergency, etc.). Will camper be taking medication during the program? (Please note that camp staff will not administer medication except EpiPen.)YesNoSection 6: Child Pick-UpThese people will be the only people allowed to pick child up at the end of camp session. DO NOT FORGET TO INCLUDE YOURSELF. They must be able to present a valid ID. People picking up a child must sign a short release form. Please note: Camp activities end at 4:00 p.m. Children may be picked up anytime between 4:00 p.m. and 4:30 p.m. There will be an additional charge of $1.00 per minute for each late pick-up after 4:30 p.m.Name of 1st Authorized Person to Pick Up Your Child First Last Phone*Name of 2nd Authorized Person to Pick Up Your Child First Last PhoneName of 3rd Authorized Person to Pick Up Your Child First Last PhoneName of 4th Authorized Person to Pick Up Your Child First Last PhoneSection 7: Camper Pledge* I agree to the following camp rules: 1. I will be respectful towards the staff, specials guests and other campers. 2. I will get along with other campers. 3. I will be polite and remember to use my manners. 4. I will be kind to the other campers and camp staff. 5. I will use appropriate language and voice. 6. I will follow Johnson GEO CENTRE rules. 7. I will listen to the Camp staff and the Johnson GEO CENTRE staff. 8. I will stay with the group at all times. 9. I will always check in and out with a Camp Counsellor before leaving the group. 10. I will have fun! I understand that if I do not follow these rules, I may not be allowed to participate in some activities. I also understand that if I cause problems in the program, my parents may be called and I may be sent home.Section 8: Waiver* I have read the behaviour guidelines (Section 7) and discussed them with my child. I understand that the Johnson GEO CENTRE reserves the right to terminate the registration of any camper if, in the opinion of the Camp Leader, it is in the best interest of the child and/or other campers. * In the event of a non-life threatening emergency, should my child require emergency treatment while at Camp GEO! and I am unable to be contacted, I authorize medical emergency treatment as necessary and I accept responsibility for any costs incurred. * In the event of a life threatening emergency, I authorize emergency treatment prior to being contacted, and I accept responsibility for any costs incurred. * I hereby waive and release all rights and claims for damages against the Johnson GEO CENTRE and their employees and agents for all injuries which may be sustained while my child attends Camp GEO! day camp. I understand the content of the program and the risks of personal injury therein. * I acknowledge that everything declared in this form is true, and I understand that if there is any change to the information contained in this form, it is my responsibility to notify the Johnson GEO CENTRE. Section 9: Photo Release Form I give permission to the Johnson GEO CENTRE to use photographs of my child in any promotional materials of the Johnson GEO CENTRE (i.e. posters, flyers). I fully understand that there will be no compensation paid for the use of these photographs. As well, the Johnson GEO CENTRE has permission to change the image through digital manipulation. I understand that my child will not be identified by name in any promotional materials. Section 10: PaymentFor each day of Easter Camp 2015, Price: $ 40.00 CAD A 10% Discount is applied for children attending five days of Camp. All GEO Members get an additional 10% off.How many days will your child attend our Camp?1234510% Discount for Five Days of Camp Price: -$ 20.00 CAD Membership #GEO Members receive a 10% discount on the price of our Camps. Enter your 7-digit membership number. Do not include the letter M at the start of your number.10% Discount for GEO Members Price: -$ 4.00 CAD 10% Discount for GEO Members Price: -$ 8.00 CAD 10% Discount for GEO Members Price: -$ 12.00 CAD 10% Discount for GEO Members Price: -$ 16.00 CAD 10% Discount for GEO Members Price: -$ 20.00 CAD Total $ 0.00 CAD Method of Payment*Credit CardDebitChequeCashPaying by Credit CardPlease phone Deb at (709) 737-7878 or fax (709) 737-7889 to provide your credit card details. Registration is not complete until payment has been made and you have been notified of your child being registered.Paying by DebitPlease phone Deb at (709) 737-7878 or fax (709) 737-7889 to make arrangements to come in to the GEO CENTRE to use your debit card. Registration is not complete until payment has been made and you have been notified of your child being registered.Paying by ChequePlease make cheques payable to "Johnson GEO CENTRE." Cheques may be mailed or dropped off to the attention of Deb Calvetti at the Johnson GEO CENTRE. Registration is not complete until the cheque has been received and processed, and you have been notified of your child being registered.Paying by CashCash payments may be dropped off to the attention of Deb Calvetti at the Johnson GEO CENTRE. Registration is not complete until the cash has been received and you have been notified of your child being registered.Cancellation Policy:You may cancel your child’s registration at any time up to 2 weeks (14 days) before the start date and receive a full refund. Cancellations made or requested after 14 days and at least 7 days prior to the start of the camp will be refunded the amount paid less a $35 administration fee per child. Cancellations made or requested less than 7 days prior to the start of the camp will be refunded 50% of the total cost. The Johnson GEO CENTRE reserves the right to cancel camps due to insufficient registration. In the event of this, parents of registrants will be notified as soon as possible and receive a full refund.