| ------------------------------------------------------------------------------------------------------------ Registration Form: Medical Information: Name________________________ Name_____________________________ Date of Birth__________________ Health Card________________________ Address______________________ _____________________________ Do you have: _____________________________ Any drug allergies?___________________ Phone________________________ Asthma?___________________________ e-mail________________________ Epilepsy?__________________________ Home Church__________________ Insect bite reaction?__________________ _____________________________ Other Allergies?_____________________ Is this your first time at Mira _________________________________ Pines?________________________ Other medical information____________ Is there somebody you'd like to __________________________________ share a cabin with?_____________ __________________________________ _____________________________ Are you taking any medication? If So what is it?_________________________ Send a 50.00 pre registration fee __________________________________ (non-refundable after June 30) _______________________________ with this form to the registrar. If you have special dietary concerns, Your spot will be reserved after the please be in touch with the camp cook a pre-registration fee is received. week before camp begins. For which week of camp are you registering?____________________ Do you have any special needs?_________ registrar - Louise MacDonald ___________________________________ 32 Tain St., Sydney ___________________________________ B1P 1Y4 ___________________________________ 539-4019 Emergency: After June 30th, call the camp In case of an emergency, I give permission director regarding vacancies or to the camp director to hospitalize, and changes, at 727-2526. secure medical treatment for this child. Signed_____________________________ T-SHIRT SIZE CHILD ADULT ___SMALL ___SMALL ___MEDIUM ___MEDIUM ___LARGE ___LARGE ___X-LARGE ___X-LARGE |
| WHAT DOES IT COST? 125.00 for five day camps 80.00 for three day camps T-shirts and camp photos included |
| ----------------------------------------------------------------------------------------------------------- IF THE PRICE OF CAMP IS A PROBLEM, THERE ARE SOME BURSARIES AVAILABLE, CONTACT THE UNITED CHURCH MINISTER NEAREST YOU. |