CarpRidgeHomeSchool Wilderness Program

Registration Form

Session (Fall, Winter, Spring): ______

PARTICIPANT INFORMATION

First Name: ______Last Name: ______

Age: ______Birth date (yy/mm/dd): ___/____/_____ Male ם Female ם

Allergies/Dietary Restrictions:______

CONTACT INFORMATION

Main Contact

First Name: ______Last Name: ______

Address: ______City: ______Province: ______

Postal Code: ______E-mail: ______

Phone #: ______Work #: ______Cell #: ______

Relationship to participant םparent םguardian םother ______

Authorized to pick up participant (must be given in writing or in person by the legal guardian)

1) ______2) ______

I would like to receive program information & updates by םe-mail םmail

Secondary Contact

First Name: ______Last Name: ______

E-mail: ______

Phone #: ______Work #: ______Cell #: ______

Relationship to participant םparent םguardian םother ______

Alternate Emergency Contact (will only be used if main and secondary contact cannot be reached)

First Name: ______Last Name: ______

Phone #: ______Work #: ______Cell #: ______

Relationship to participant םparent םguardian םother ______

Code of Conduct

Developing an understanding of and responsibility for individual potential and abilities includes accepting responsibility for individual actions. While under the leadership of skilled staff, the activities that your child will engage in as a participant at the Carp Ridge Learning Centre involve risk – in choices made by the participant. As a condition of being allowed to participate in Carp Ridge Learning Centre programs, you warrant the participant is in good physical and mental health and that the participant shall not consume any substances which would impair the participant’s senses at any time during the program. You agree that intentional participant behaviour that puts the participant or others at physical or emotional risk will result in immediate dismissal from the program at the discretion of the centre’s Director. Expenses incurred because of program dismissal will be the responsibility of the participant/parent/guardian.

Release
I, the undersigned, permit participation in a full range of activities and authorize the Program Director or his/her appointee, in the event of an accident or illness, to authorize on my behalf all procedures, including admission to hospital and necessary treatment therein, as he/she may deem essential for the care and well-being of the participant. I also give my consent forCarp Ridge Learning Centreto use the participant’s photo taken at camp which may be used for Carp Ridge Learning Centre promotions, unless Carp Ridge Learning Centre is advised otherwise in writing. I have read, understand and agree to the terms of the refund/transfer policy, code of conduct and payment procedures.
______
Parent/Guardian Signature Name (please print) Date
The Fine Print:
•We will refundyour deposit in the event that we cancel the program.
•If you need to cancel, please notify us immediately. If cancellations aremade prior to 14 days from the start date of the course, a full refund will be given.
• Cancellations made less than 14 days before the program will be refunded 50%, and cancellations made less than 7 days before the program will not receive a refund, unless in the event of illness or special circumstances, in which case will be reviewed by the Director.
•Any person who leaves duringthe middle of a program due to illness, injury, expulsion, or any other reason will not be refunded any portion of the course fees.
Payment can be made by cash or cheque. Please make cheques payable to:
Carp Ridge Learning Centre
Amount $ ______

Thank You! We are looking forward to meeting you!

Once you have registered, you can look forward to receiving a call from our office. We will provide you with details on packing lists, directions, and program specifics.

Mail or fax a completed application to:

Carp Ridge Learning Centre, 2386 Thomas Dolan Pkwy, Carp ON, K0A 1L0

Phone: 613.839.1179

Fax: 613.839.3909