Overnight Summer Camp: Week 6 - Individual Registration

Camper First Name *

Camper Last Name *

Gender *

Male

Female

Address *

Unit Number

City *

Province *

Postal Code *

Country *

Home Phone

Parent Email *

Alternate Parent Email

Note: All information, including statements of payment, may be sent to both emails on file.

Birth Month *

Day of Birth *

Birth Year *

Age at Camp Time *

Best Number to Reach You *

Name of Mother/Guardian *

Mother Cell *

Mother Business Phone

Name of Father/Guardian *

Father Cell *

Father Business Phone

Camper Lives With *

Emergency Contact Name *

Please ensure the emergency contact is not a parent/guardian of the child.

Emergency Contact Relationship *

Emergency Number *

Is this the camper's first time attending WSC? *

Yes

No

The last year the camper attended Willow Springs Camp was:

How did you hear about Willow Springs Camp?

If you attend, what is the name of your home church?

Camp Shirt Size *

Cabinmate Request

We do our best to honour cabinmate requests!

Ontario Healthcard Number (10-digit number) *

Healthcard Version Code (The 2 LETTER Code) *

Family Doctor Name *

Doctor Phone *

Medical Conditions - Check if the child currently or within last 3 months has had any of the following:

Information about Medical Condtions

Please include any information about physical, mental, and/or emotional conditions and any restrictions the child may have.

Past Medical Operations (please list)

Other Medical Information we should be aware of

Allergies *

Yes

No

Is the allergy life threathening? *

Yes

No

Please contact the camp if your child has a life threatening allergy. We require a signed allergy consent form before your child attends their week of camp.

Allergy Details *

Penicillin

Other Drugs

Bee Stings

Food

Other

Penicillin Allergy *

List the type of penicillin reaction:

Bee Allergy *

List the type of bee reaction

Other Drug Allergy *

List the name of the drug and the type of reaction:

Food Allergy *

List the food(s) and type of reaction(s)

Other Allergy *

List any other allergies and reactions that were not mentioned:

Medications Bringing to Camp

Please note that for the safety of all campers, all medications brought to camp — including prescription and over-the-counter items such as tablets, liquids, creams, inhalers, supplements, etc. — must be given to our Health & Safety Administrator at check-in. Campers may not keep any medication with them or in their cabins.

Campers with severe allergies who require an EpiPen are permitted to carry their primary with them at all times.

Can Tylenol be given if necessary? *

Yes

No

Can Ibuprofen be given if necessary? *

Yes

No

Ibuprofen Examples: Advil or Motrin

Has camper had a tetanus shot in the last 10 years? *

Yes

No

What is the date of the last tetanus shot?

In case of emergency *

In case of emergency I understand every effort will be made to contact me. In the event that I cannot be reached in an emergency situation, I hereby give permission to licensed emergency and health care personnel to provide treatment, services and transport necessary to maintain the health of my child(ren). In the event medication, medical advice, treatment and/or equipment are required, I agree to accept financial responsibility for fees in excess of provincial and or private medical insurance. I agree that the information on this form may be disclosed to such emergency and health care personnel. In the event of illness, accident, emergency, or any other circumstance requiring medical treatment, such treatment may be procured for the participant(s) without legal or financial obligation to Willow Springs Camp and One Hope Canada. All known health issues of my child(ren) have been stated to the camp. I will notify the camp if my child(ren) is exposed to any infectious diseases prior to arriving at camp.

I agree to allow photographs *

Yes - I agree to allow photographs or video of camp activities, which may include my child(ren), to be used in any and all camp promotional material including the sharing of photographs and videos with ministry partners of One Hope Canada.

No - I do not agree to the above statement.

Understood the terms of this agreement *

I have read and understood the terms of this agreement and BY ALLOWING MY CHILD(REN) to participate in the camp, I am voluntarily agreeing to abide to these terms. I confirm that the participant [my child(ren)] is physically and mentally able to participate in all activities of the camp, unless specifically indicated otherwise in writing.

Right to request *

Willow Springs Camp reserves the right to request any participant(s) to withdraw from their camp if the participant is not acting in an appropriate and responsible manner.

Right to cancel *

Willow Springs Camp reserves the right to cancel any week of camp and give a full refund less the deposit amount.

Agree to share

I agree to allow Willow Springs Camp to share my name, address & phone number with personnel & churches affiliated with the camp.

Permission to connect

We count it a privilege that you are sending your son(s) and/or daughter(s) to spend the week with us at camp this summer. During a week of camp, we look forward to many great friendships being formed! We have an amazing summer missionary team, and they love to stay connected with their campers throughout the year to hear how they are doing and answer any questions they may have about the topics discussed during chapel sessions and cabin devotionals. As part of our child and youth protection policy (www.insafehands.ca) we are committed to honouring you as a parent/guardian and to asking your permission before any contact occurs between campers and our missionaries (e.g. TWELVE, emails, phone calls, etc.). Our missionaries would be honoured to be able to continue to stay involved in your child(ren) or youth’s life after camp. Please initial to indicate whether or not you give permission to our missionaries to stay in contact with your son(s) and/or daughter(s). If you wish to discuss this further, please contact the camp director by phone or email (please see camp website for contact information). If you wish to withdraw your permission, please contact the camp office immediately to notify the camp director.

Privacy Policy: Click here to read how we handle your child's personal information.

IN CONSIDERATION *

IN CONSIDERATION of being permitted to participate in any way at (Willow Springs Camp), operated by One Hope Ministries of Canada (hereafter known as ministry point), I acknowledge, understand, and agree: 1. Participation in activities could result in possible personal injury. Despite precautions taken by the ministry point, accidents and injuries may occur. By signing this form, I assume all risks related to the use of any and all spaces used by the ministry point. 2. To release from responsibility, the ministry point, including all missionaries, full-time and part-time, paid or volunteer, and the facilities used from any cause of action, claims, or demands now, and in the future that might arise out of the participant’s participation in activities at the ministry point or from the physical risks associated with the activities. 3. I accept all risks relating to such activities including personal injury such as: cuts, sprains, scrapes, bruises, fractures, broken bones, concussions, death, or any personal property damage/loss, which may occur on the camp premises. I understand these risks and will not hold the ministry point liable for any such injury. 4. Furthermore, I agree to obey all ministry point rules and take full responsibility for my behaviour in addition to any damage I may cause to the facilities utilized by the ministry point.

I have read *

I have read this Informed Consent and Assumption of Risk Agreement, fully understand its terms and the risks I am assuming by signing it, and sign it freely and voluntarily.

I, the participant, *

I, the participant, have read this Informed Consent and Assumption of Risk Agreement, fully understand its terms and the risks I am assuming by signing it, and sign it freely and voluntarily.

This is to certify that *

This is to certify that, I, as Parent/Guardian with legal responsibility for this participant(s), have read this Informed Consent and Assumption of Risk Agreement, fully understand its terms, and that I have given up substantial rights by signing it, and sign it freely and voluntarily.

Discounts will be applied and your final price will be adjusted once it reaches head office.

How many children from the same household are you registering for camp? *

A $50 Sibling discount will be applied to each additional child after the first.

(i.e. You register two children that are siblings, each of them for two weeks of camp. A $50 discount would be applied to the second child for their first week of camp only.)

I have referred ___ campers to Willow Springs Camp for the first time. *

My New Friend's First and Last Name is: *

Please list the first & last names of all new friends you've referred.

This discount is $50 off total fees per each friend referral and will only be applied once the referred friend has registered and paid their deposit.

E.g. A camper you referred signs up for two weeks, and your child attends camp for two weeks, the discount remains at $50.

Ministry Discount

Is this registrant's household exclusively supported by parents/guardians in full time ministry?

How do you intend to pay? *

Amount

Payment Method

Cash, Cheque, E-Transfer or Credit Card

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Holder Name*

Individual Registration

Medical Information

Parent/Guardian Permission Form

Informed Consent and Assumption of Risk

Participant Signature (13 years and older)

FOR PARTICIPANTS OF MINORITY AGE

Discounts

Payment Information