Wakefield Summer Film Camp
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Summer Film Camp '12
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Registration Form
Fields marked (
*
) must be completed.
If the form fails to submit please check the highlighted fields.
Camp Week
*
Week 1 FULL
Week 2 July 15 - July 19
Week 3 July 29 - August 2
Week 4 August 5 - August 9
$275.00
Participant's Name
*
First
Last
Gender
*
Male
Female
Date of birth
Day
*
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
Address
*
Address
*
City/Town
*
Postal Code
*
Province
*
Mother's Name
*
First
Last
Home Phone Number
*
-
-
Work Phone Number
*
-
-
Email
*
Father's Name
*
First
Last
Home Phone Number
*
-
-
Work Phone Number
*
-
-
Email
*
Name of Emergency Contact #1
*
First
Last
Relationship
*
Phone Number
*
-
-
Name of Emergency Contact #2
*
First
Last
Relationship
*
Phone Number
*
-
-
Health Card #
*
Allergies
*
Food Allergies
Enviromental Allergies
Epipen
Please specify:
*
In case of emegency
*
This is to confirm that I give permission to the staff at the Wakefield Summer Film Camp to have my child admitted to the Gatineau Memorial Hospital in case of emergency.
Name
*
First
Last
Submit