Registration Form

Fields marked (*) must be completed.
If the form fails to submit please check the highlighted fields.

Camp Week *

$275.00

Participant's Name *

First

Last

Gender *

Male Female

Date of birth

Day *

Month *

Year *

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