Canadian Parents for French
Summer Language Camp Application Form 2015
Francoforum, St. Pierre et Miquelon
Deadline for Applications: May 15, 2015
Section A – Student Identification (to be completed by student)
Last Name / First NameInitials / Grade / T-Shirt Size / Sexe
M F / Age / Date of Birth
/ /
mm dd yy
Mailing address / Province / Postal Code
Phone number / Other contact number
E-mail address
What is your first official language? English French Other ______
Please specify
Are you a: Canadian Citizen Permanent resident Protected-person status Other ______
Specify
Section B – Student Health and Medical Intervention (to be completed by student and parent and signed by parent)
MCP # / Family Doctor / Family Doctor Phone NumberDo you have any allergies? Yes No
If yes, please list in space provided.
Are there any over-the-counter drugs that cannot be administered (ex. Tylenol, etc.)? Yes No
If yes, please list in space provided.
Are you taking prescription drugs? Yes No
If yes, please list in space provided along with a schedule for when they are to be taken.
Are all vaccinations up-to-date? Yes No
Please list the date of the last Tetanus immunization in the space provided. / (yy/mm/dd)
Is there anything in your medical history of which we should be aware? Yes No
If yes, please list in space provided. Please note any outstanding medical issues (i.e. medical, physical, social or behavioral difficulties or weaknesses. If necessary, send attachments with full details).
Do you have special diet requirements? Yes No
If yes, please list in space provided.
Do you smoke? Yes No
How do you plan to travel to St. Pierre?
Boat (Ferry leaves from Fortune, NL. If you plan to take the ferry please indicate. CPFNL office will make the reservation however payment is the responsibility of the camper and their guardian)
Place (Flights leave from St. John's NL. If you plan to fly to St. Pierre please inform the CPFNL office. CPFNL office can assist with the reservation and accommodations for pick up from the airport will need to be made. Cost of flying is the responsibility of the camper and their guardian)
Would you be interested in Carpooling with another camper?
Section C – Student Academics and Interests (to be completed by student)
School (name in full) / School district (name in full)School Mailing address / Province / Postal Code
Phone Number / School e-mail address
Teacher contact / Teacher e-mail address
Program enrolled (check one)
Core French Immersion / # of French courses studying / Average Grade in French
Section D – Student Study and Behaviour (to be completed by student)
Please check all boxes before submitting the application form. A failure to complete and sign this section will result in the cancellation of this application.
I understand that I will be housed with a host family or hotel/motel accommodations. I agree to abide by the rules of my host family/chaperones such as presence at meals, the use of tobacco, curfews and any other established rules. I recognize that the parents of my host family or chaperones are to exercise all regular parental responsibilities towards me.
I will make every effort to speak French at all times.
I will not leave the group without permission.
I understand that CPF-NL or the Francoforum is not responsible for stolen articles.
I agree to conduct myself in a mature manner, to respect my community and to make full use of this opportunity to learn about St. Pierre et Miquelon and appreciate its culture.
I am available for and agree to participate in the entire program (June 26 to July 1, 2015).
I agree to fill out and return the program’s evaluation form(s) to the appropriate parties.
I agree to be photographed/recorded during the course of the Summer Language Program and that such photographs and/or recordings may be used for advertising and publicity purposes.
I have read and understood the above rules. I agree to abide by them and to sign this application.
Signed:______
Name:______
(please print)
Date: ______
Section E – Parent/Guardian Identification (to be completed by parent/guardian)
Please provide parent/guardian information in case of emergency
Last Name / First NameMailing address / Province / Postal Code
Phone number / Cell phone number
Relationship with Summer Camp participant / E-mail Address
Other contact in case of emergency / Relationship with participant / Contact phone number
Are you a member of Canadian Parents for French? Yes No
Is the school that your child attends a member of Canadian Parents for French? Yes No
Please check all boxes before submitting the application form. A failure to complete and sign this section will result in the cancellation of this application.
I hereby authorize ______to take part in the Summer Language Camp at the Francoforum. My child and I understand that the SLC is an educational excursion.
I agree to pay for my child’s registration fee ($500 for students of CPF Members and $550 for students of Non-CPF Members), all transportation costs to and from St. Pierre et Miquelon and spending and pocket money and have included the $200 deposit per child with this application.
I agree to pay for my child’s return trip if s/he is removed from the program for using drugs or alcohol or for a serious behaviour problem as stipulated in item 5 of Section D.
I agree to accept responsibility for any additional costs in the unlikely event of a delay in St. Pierre due to cancellation of service by the carrier.
I am aware that certain risks may be associated with an educational excursion of this kind. I believe that my child is capable of participating in this type of project and has the necessary physical health and maturity to do so. I have read and agree to all of the terms and conditions of this program.
Signed:______
Name:______
(please print)
Date: ______
Make sure you remember to:
1)Complete and sign the application form
2)Obtain and send letter of reference from your school principal or French teacher
3)Have your parents/guardians read and sign Section E
4)Obtain your passport (The French Government now requires all passengers traveling to St. Pierre et Miquelon to have a valid passport).
CPF-NLFrancoforum
P.O. Box 8601, Station ABoulevard de Port en Bessin – BP 4382
St. John’s, NL A1B 3P2Saint Pierre et Miquelon
Tel: 709.579.1776 / 877.576.1776Tel: 011.508.41.24.38
Fax: 709.579.0833Fax: 011.508.41.39.29
nl.cpf.ca
This program is made possible with the assistance of the Department of Canadian Heritage and the Francoforum.
Promoting opportunities for young Canadians to learn and use French
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