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					                                UNITED CHURCH OF CANADA
                                    REGISTRATION FORM
                         "Christmas in July!" from June 26 to July 1, 2011

Name:                                                              Mother’s Full Name: (maiden)
                                                                   Father’s Full Name:

Telephone: (             )
E-mail:                                                            Who will pick up your child?

Male (      ) Female ( )                                           Name of Church & Minister:

Age as of September 30, 2011:
Date of Birth: yy/mm/dd                                            Attended camp before? yes ( ) no (                     )
Grade finished this year:                                          If “yes”, where?
Swimmer ( ) Non-swimmer ( )                                        Permission to post photos of your child on:
Special needs:                                                     A) Presbytery & camp Web sites: yes ( ) no ( )
                                                                   B) United Church publications: yes ( ) no ( )
Dietary restrictions: (vegetarian etc.)                            C) Other, i.e. The Record: yes ( ) no ( )
                                                                   Parent’s Signature(s)
Cabin mate preference: (this cannot be
                                                                   Please return this form and a deposit of $100
                                                                   Balance of $200 due on arrival at camp**
                                                                   Cheque is to be made payable to
                                                                   Q/S Presbytery Camp and sent to:
                                                                   Lois Fowler, Registrar
                                                                   159 route 116
                                                                   Richmond, QC J0B 2H0

For campers 15 years and older as of September 30, 2011, we offer leadership training.
Activities for this camping group will evolve according to their program.

Our activities include canoeing, crafts, fishing from a motorboat, games, hiking,
nature walk, kites, music, sacred sculpture, science, sports, t-shirts.
                                        Our Mission Statement:
                          " TO CREATE A SPACE WHERE THE SPIRIT CAN ACT"
              We build a space which is safe, healthy and affirming with an openess to God, to encourage
                           people to develop a sense of security and Christian Community.

I understand that Q/S Presbytery camp is not responsible for lost, stolen or damaged property. ________
                                                                                                                          initials please

I hereby authorize the Health Care Personnel and/or Camp Director to secure such medical
advice and services as may be deemed necessary for the health and safety of my child (or ward) or myself.
I agree to accept financial responsibility in excess of the benefits allowed by the Provincial Health Insurance Plan.
______________________________________________________ Date: ___________________________
Signature of Parent (or camper/staff if over provincial legal age)

** Cost is $300 per child. 3rd and subsequent children from the same family are $150.
** Register before May 15 and get $25 off. Also receive a $25 discount for recruiting other campers. Max. discount $50.
                                                                                    PLEASE SEE ATTACHED FOR HEALTH FORM

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