LAROCCAXC REGISTRATION 2012 Applications must be filled out in full, signed and accompanied by the appropriate payment. All fees are non-refundable except with a physician’s certificate. A confirmation call will be made upon receiving registration. WE MUST HAVE A MINIMUM OF 15 CAMPERS PER WEEK. BUS TRANSPORTATION NO LONGER PROVIDED DUE TO VARIOUS FACTORS. WE HAVE HAD GREAT SUCCESS WITH CAR POOLING IN THE PAST THREE YEARS! WE ARE ONLY 20 KM FROM THE ALONZO BRIDGE. HELP US BRING THE KIDS TO THE GREAT OUTDOORS! Make cheque payable to Creative Wheel or LaRoccaXC Mail to: Creative Wheel, 327 Route Principale, Val-des-Monts, QC, J8N 4B7 Name: D.O.B.: Age: Address: City: Postal code: email: Tel. H)#: Tel. Cel)#: Tel. W)#: ext. Emergency contact (name and relationship): Tel. H)#: Tel. Cel)#: Any medical concerns/past injuries/allergies you wish to share with us? Please use the back of the form to share information that you feel would help us serve your child better. All information is kept confidential. Thank you. ADDITIONAL FAMILY MEMBERS: Name: D.O.B.: Age: Name: D.O.B.: Age: CAMP FEES / RPS Camp and the Environmental Stewardship Program $325 + taxes (total $373) (Week of July 9, July 16, August 6, August 13, August 20) WILD WOMEN WEEKEND FEES $150 + taxes (total $173) (June 2-3 or June 9-10) Please circle the week(s) of camp you wish to send your child. Youth Summer Camps (#1) July 9 (#2) July 16 (#3) August 6 (#4) August 13 (#5) Aug. 20 Women’s Weekend (#1) June 2-3 (#2) June 9-10 Bike Rental Yes! I will need bike rental. ½ day ($29) Full day ($40) Weekend ($63) METHOD OF PAYMENT (post dated cheques option available). Cheque(s) MASTER CARD, VISA CASH Card #: Expiry date: Name of cardholder in print: Signature: NEW! DROP IN OPTION: Kids/youth who have participated to one week of camp (2012) can choose a drop in option for a daily fee of $63/day from Wednesday to Friday. Special conditions apply. Please email firstname.lastname@example.org for more information.
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