Kiddie Camp Registration Form for Summer 2019

Camper Information

First Name
Middle Name
Last Name
Date of Birth (dd / mm / yyyy)
/ /
Age: ( from 4 to 7 )
Sex:
F M
Home Street Address
City
Province / State
Country
Postal / Zip Code
 

PARENT / GUARDIAN 1 NAME:

Home Phone
Day/Cell Phone
E-mail

PARENT / GUARDIAN 2 NAME:

Home Phone
Day/Cell Phone
E-mail

SESSION INFORMATION

(All fees in Canadian Dollars and Includes Tuition plus HST (13%) where applicable)

Price / Day = $57.00

  Day Camp Term Ends Total
Week One July 2 to July 5, 2019 Tue Wed Thur Fri
Week Two July 8 to July12, 2019 Mon Tue               Thu Fri
Week Three July 15 to July 18, 2019 Mon Tue Wed Thu
Week Four July 29 to August 2, 2019 Mon Tue Wed Thu Fri
Week Five August 5 to August 9, 2019 Mon Tue               Thu Fri
Please mark off the week or weeks and the days in each week your child will be attending, please total for the week.
TOTAL:

*Hours 10:00am to 4:00pm. (*Camp Time) Lunch is included. Payment will be required in full before the start of each session. We do offer camp store after lunch for all campers to enjoy a small candy or two, additional monies may be charged for camp store expenses. Camp Time please check website.

Payment Information

Master Card Visa Cheque
Authorized Amount
Card Number
Expiration Date
Name on Card
Authorized Signature
CVV No. (back of card):

Each session can be paid by Cheque, Visa, MasterCard. An information package containing details of the, Sign In & Out Sheet, Medical & Clothing List is available on our website. Payment in full is required before the start of each session.

HOW DID YOU HEAR ABOUT Camp Ak-O-Mak?

Friend Exhibit/Display Advertisement
  please let us know the location
which publication/website?

PARENT/GUARDIAN INFORMATION

I agree Camp Ak-O-Mak is released from liability in connection with medical treatment and unavoidable accidents. Camp Ak-O-Mak has my permission to use necessary medical measures in the event of an emergency. My child has permission to leave the campgrounds with authorized camp staff for scheduled trips and outings. Also, I give Camp Ak-O-Mak permission to utilize my child`s photograph or likeness in camp promotional materials.

I Agree

Parent or Guardian Signature: Date:

Business Office: 14-441 Stonehenge Drive, Ancaster, Ontario, Canada L9K 0B1,
Tel.: 416.427.3171, Fax: 905.304.2982
Email: Dianne@campakomak.com Website: www.campakomak.com

Summer Address: 240 Akomak Road, Ahmic Harbour, Ontario, Canada P0A 1A0,
Tel.: 705.387.3810, Fax: 705.387.0077