Camp Opemikon – Summer 2017 Registration Form

Name:______

SurnameGiven Name(s)

Home Address:______

______Home Phone:(____)____-______

E-mail address:______

Male Female

Age (as of this June 1) Years ______Months ______

Date of Birth: ______(yyyy – mm – dd)

CAMP PERIODS: / July 1-8 / July 8-15 / July 15-22 / July 22-29 / July 29-August 5 / August5-12
PLEASE INDICATE (X) FOR DESIRED PROGRAM PERIOD BELOW:
Junior
  • Beaver (Thurs-Sat)
  • White Tail (Sat-Tues)
  • Gold Pack
  • Red Pack
  • Black Pack
Intermediate
  • Brownsea
  • Scoutcraft
  • Survival Camp
  • Paddling I/Kayaking
  • Paddling II
/ 4
 4
 1
 1
 1
1
 1
5
1
 5 /  2
 2
 2
2
 2
 6
2
 6 /  3
 3
 3
 3
 3
3 /  4
 4
 4
 4
 4
4 / 5 6 / Senior Adventures
  • Rocks Camp
  • Outdoor Skills & Leadership*
  • Counselor-In-Training*
  • Seneca*
* Two-week Program (No Break)
/  2
 1 - 2
 1 - 2
 4 - 5
 5 - 6 / 4
 3 - 4
 2 - 3 /  5 - 6
3 - 4
TRANSPORTATION: Camper will arrive to camp by private vehicle Camper will depart camp by private vehicle
Camper will be taking bus to and from camp Camper will be taking bus to camp Camper will be taking bus from camp
Opemikon will provide a bus that will arrive/depart from the parking lot of the Scout Office at 1345 Baseline Rd., Ottawa. Please indicate above if your child requires bus transport either to or from camp. Should this change, we MUST be notified IN WRITING by fax or e-mail at least 3 business days prior to transport.
E-mail: Office Fax: 613-225-2802 (Ottawa)
PARENTAL/GUARDIAN AGREEMENT:
It is understood that should I cancel this application, the fee, less a $50 administration charge, will be refunded. I have fully completed and attached Consent/Contact/Medical Information form and the Camper Code of Conduct. The information on the form is current and correct. Any amendment will be provided in writing to the Scout Office prior to the first day of camp.
Parent/Guardian’s Name (print): ______Signature: ______
Date: ______
PAYMENT OF FEES: (This portion will be detached and destroyed after payment is processed.)
Camp Fee: $______
Method of Payment: HST (13%) $ ______
Cheque/Money Order (payable to Scouts Canada) attached/enclosed Scout Registration Fee: $ ______
Visa/Mastercard #: ______Expiry Date: _____/______($50 FOR NON-MEMBERS)
Card Holder’s Name: ______MM / YY TOTAL: $ ______