2015 CAMP KRETINGA APPLICATION FORM

2015 CAMP KRETINGA APPLICATION FORM
SURNAME:
July 12th- July 25th
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NAME:
July 26th- August 8th
CONTACT INFORMATION
Address (Street, City, Province/State, Postal/Zip Code):
Parent Email:
Camper Email
Phone (Home):
Mother’s Information
Name:
Maiden Name:
Phone:(Cell)
Father’s Information
Name:
Phone: (Home)
(Cell)
(Home)
(Bus)
(Bus)
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FEES AND PAYMENT
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(Ext)
(Ext)
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Camper name(s)
Each additional child: $350 for 2 weeks
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Shirt size (Adult sizes only)
S
M
L
XL
Fees for all campers
$
S
M
L
XL
Donation
$
S
M
L
XL
Total
$
S
M
L
XL
*
RELEASE The following are understood by any parent or guardian submitting this application:
1. That any child applying for camp is in good physical and emotional health and amenable to normal camp authority and discipline;
2. That any parent or guardian submitting this application is legally responsible for the payment of fees and other expenses incurred by the child;
3. That the camp staff at their discretion
terminate the stay of any camper who is adverse to discipline or camp rules. In the case of an accident, I will not
hold the camp staff, or particular counselors, or the campground owners accountable.
4. Permission is given by parent or guardian for camper to leave camp grounds for supervised swimming and
5. In the case of an emergency, I give permission for any necessary medical procedures.
6. Photos of campers involved may appear on the video or the internet
Parent/Guardian Signature:
Date:
ACCEPTABLE METHODS OF PAYMENT:
1. By Cheque: Payble to: Kretinga Inc.
2. By Email Money Transfer: Send payment to Kretnga.Board@gmail.com
*Both Lithuanian Credit Unions now support Email Payments!
Anyone who cannot afford the camp fees, please Email: Kretinga.Board@gmail.com to request a
Bursuary Application Form that will be reviewed by the Kretinga Board.
CAMPER INFORMATION & HEALTH FORM
NAME:
Date of Birth:MM
Age at camp:
Grade completed by camp:
Speaks Lithuanian
 Fluently
Bringing musical instrument
 No
 Male
 Understands
 Female
 Not at all
 Yes
Special talents:
HEALTH APPRAISAL
Insurance
 OHIP
Health Card Number:
 Other
(Company name, phone number, policy number)
*
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(REQUIRED):DDYY
ATTACHED TO THIS FORM
 YES
 NO-----* PLEASE PROVIDE FURTHER INFORMATION:
Medications
 None
 Yes----*REASON:
Doctor
(Name, address, phone number)
Date of last tetanus: DD / M M / YYYY
Allergies
 None
 Yes----*INSTRUCTIONS:
Special Problems (bedwetting, sleepwalking, etc.)
 None
 Yes---*EXPLAIN:
Instructions:
Does your child have any Behavioural Problems:
 None
 Yes----* PLEASE EXPLAIN:
Is the child able to participate in all camp activities?
 Yes
 No----*RESTRICTIONS:
Guardian Signature
Date
Doctor Signature
Date