Please complete a separate application form for each camper
Form must be complete and signed by Parent/Guardian or Camper (if 18 years of age)

Camper's Name: (last)

(first)

Ontario Health Card Number:

Family Email Address:

Camper's Address:

City/Town:

Province:

Postal Code:

Home Phone Number:

Date of Birth: (Month/Day/Year)

Have you ever been to a Camp Kahquah summer camp program before?

Indicate ONE choice of cabin mate:
(We will try to put friends in the same cabin, but cannot guarantee it. Both campers must indicate that they would want to be in the same cabin)

Bring a Friend?
(Let us know if you are bringing a friend to Camp this summer. If it is their first time at Kahquah, we want to share a $5 tuck credit with you.)

Home Church (if attending):

Male Parent / Guardian Name:

Parent / Guardian Work Phone Number:

Home:

Female Parent / Guardian Name:

Home:

Parent / Guardian Work Phone Number:

Emergency Contact (Other than Parent):

Relationship:

Phone Number of Emergency Contact:

Family Doctor:

Phone:

Please give any relevant
details for the nurse:

Please give specifics and
list any other allergies:

Medication 1

Dosage

Times Taken

Medication 2

Dosage

Times Taken

Food Allergy Policy: Our desire is to create a safe environment for children. We will make reasonable efforts to ensure that your child does not have a food allergy attack while at Camp Kahquah. We are not a peanut-free location. Our goal is to help children self-manage their condition. For more information call 905-387-3923.

Are there any activities at camp in which the camper should NOT participate?

Important Note: All medications must come in their ORIGINAL container. Prescription Meds must be for the child indicated on the label and all labels must have proper dosages detailed. The camp nurse will be responsible for all medications. Any outdated medications or those not in their original containers will NOT be administered to any campers while they are in the care of Camp Kahquah. The camp must be notified in writing if the camper is exposed to any communicable disease during the 4 weeks prior to camp, or if the camper's medical status changes.

By my signature and submission, I declare that the medical history attached is complete and accurate and I give my permission for a physician selected by the appointed Camp Director to hospitalize, secure proper treatment for, and to order injection, anaesthesia or surgery for my child named above in the event of a medical emergency and for the family doctor to be contacted in such a case.

Signature of Parent/Guardian
(or camper if 18 years of age)

Disclaimer Information - Parent or Guardian Consent 1. My child is in good physical and emotional health, and amendable to normal camp authority 2. The Camp Director reserves the right to dismiss a camper who is, in his/her opinion, a hazard to the safety and rights of others, or appears to him/her to have rejected reasonable camp controls 3. I, as a parent or guardian, have legal custody of the child applying to Camp Kahquah and if applicable have informed the camp of any conditions of custody. The signature on the registration form signifies that both parents/guardians are in agreement with the conditions of enrolment. 4. Care is taken for the safety and good health of campers, but in the event of an accident or sickness, Camp Kahquah, including the Board of Directors and staff, and the owners and the employees of facilities outside of the campgrounds are hereby released from any liability. Each camper must be covered by Provincial Health Insurance or equivalent medical insurance. 5. In the event that a camper requires special medication, X-ray or treatment beyond that which is available at Camp, the parents/guardians will be notified immediately and will be charged with the additional expense of transportation and special care. 6. In the event of an emergency, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure treatment for, and to order injection, anaesthesia or surgery for my child as named above. 7. Camp Kahquah requires that campers who have potentially life-threatening conditions, such as peanut allergies, to be able to manage their exposure to those substances, provide two sets of medication and be familiar with its use. 8. Permission is given for Camp Kahquah to use any image or likeness of my child for their promotional material. 9. In case of withdrawal during the Camp on a physician's order, two thirds of the remaining term will be refunded. No refund will be made for dismissals due to disciplinary action, late arrivals or early departures. 10. The deposit of $75 per week is non-refundable for cancellations made after May 15, 2010. For cancellation prior to May 15, there is a $25 cancellation fee. Less than two weeks prior to the program date, all program fees become non-refundable, unless written explanation from a doctor is received, in which case, only the deposit is non-refundable. 11. Programs that do not receive a minimum number of registrations will be cancelled and fees paid will be fully refunded. 12. The information on this form will only be used by Camp Kahquah for the specific purpose of providing your child with a memorable experience. I understand that this information will not be passed to any other group or used for any other purpose. 13. I have read and understand all pages of the brochure and this application form.

Signature of Parent/Guardian
(or camper if 18 years of age)

Please Enter the amount you plan to pay today (Q):
A minimum deposit of $75 is required for registration - remainder is due by June 15