REGISTRATION

1. Please complete the form below.
2. Print this page (File: Print, or click the button at the bottom of the form
3. Mail your printed registration form and registration fee to:

     Camp Bickell
     P.O. Bag 974
     Schumacher, Ontario
     P0N 1G0


 CAMPER'S FIRST NAME :

LAST NAME:

ADDRESS:

BOX #

TOWN/CITY:

PROVINCE:

POSTAL CODE:

EMAIL:

AGE:

  (as of June 30th, 2010)  BIRTH DATE:

SCHOOL:

 MALE  FEMALE 

HEALTH CARD # :

 DOES YOUR CHILD HAVE ALLERGIES?  YES   NO

IS HE/SHE AWARE? :

 IS YOUR CHILD TAKING ANY MEDICATION?   YES   NO

GIVE DETAILS OF ALLERGIES, MEDICATIONS AND/OR HEALTH RELATED INFORMATION:

**PLEASE ADVISE CAMP DIRECTOR AND CAMP NURSE DETAILS OF MEDICATION**

FAMILY DOCTOR:

 PHONE #: 

PARENT/GUARDIAN NAME:

 PHONE # (H):  (W):

PARENT/GUARDIAN NAME:

 PHONE # (H):  (W):

IN CASE OF INJURY OR ILLNESS AT CAMP BICKELL, I GRANT PERMISSION TO CAMP PERSONNEL TO TAKE MY CHILD TO HOSPITAL TO RECEIVE MEDICAL TREATMENT:   

Signature required on printed form:

I AUTHORIZE CAMP BICKELL TO PUBLISH MY CHILD'S PICTURES ON THE CAMPS WEB SITE:

Signature required on printed form:

PLEASE SELECT ONE OF THE FOLLOWING CAMPING DATES: