Camper Application Form

AUGUST 8 – AUGUST 15, 2020

Completed APPLICATION and PAYMENT must be received by April 1^st

Total fee per camper: $555 payable to HTAC – Diocese Camp Fund
Include camper’s name(s) and mailing address on cheque
Mailed to: CAMP ARARAT, c/o 920 Progress Av. Scarborough, Ontario, M1G 3T5

CHILD'S NAME *

First

Middle

Last

GENDER *

DATE OF BIRTH *

CHILD'S EMAIL *

Confirm Email

ADDRESS *

Address Line 1

City

State / Province / Region

Postal Code

FATHER'S NAME *

First

Last

MOTHER'S NAME *

First

Last

FATHER'S EMAIL *

Confirm Email

MOTHER'S EMAIL *

Confirm Email

HOME PHONE *

FATHER'S CELL PHONE

FATHER'S BUSINESS PHONE

MOTHER'S CELL PHONE

MOTHER'S BUSINESS PHONE

WHICH PARENT CAN WE REACH DURING THE TIME YOUR CHILD IS AT CAMP? *

EMERGENCY CONTACT PERSON & TELEPHONE NUMBER (OTHER THAN PARENT/GUARDIAN) *

CONFIDENTIAL MEDICAL INFORMATION *

FAMILY PHYSICIAN

PHYSICIAN'S PHONE

LIST ALL ALLERGIES OR SENSITIVITIES TO ANY DRUGS, FOODS, OR ENVIRONMENT *

* An additional medical form will be mailed with the welcome package and all medication will be administered to the child as directed in writing.

NAME TWO FRIENDS OR ACQUAINTANCES, OF SIMILAR AGE AND GENDER, YOU’D LIKE TO BE BUNKED WITH AND ALL OTHER CONSIDERATIONS/REQUESTS

First

Last

SELECT YOUR CAMP ARARAT T-SHIRT SIZE *

IS THIS THE CAMPER’S FIRST OVERNIGHT CAMP EXPERIENCE? *

BY SUBMITTING THIS APPLICATION I/WE CONFIRM THAT AS PARENT/GUARDIAN OF THE CHILD HAVE SOUGHT COMPETENT ADVICE WITH RESPECT TO MY/OUR CHILD’S HEALTH AND WELL BEING PRIOR TO COMPLETING THIS FORM. I/WE AGREE TO RELEASE THE ARMENIAN HOLY APOSTOLIC CHURCH CANADIAN DIOCESE, CAMP ARARAT AND ITS MEDICAL STAFF, COUNSELLORS AND SUPERVISORS OF ANY LIABILITY. IN THE CASE OF AN EMERGENCY, MEDICAL/HOSPITAL SERVICES MAY BE REQUIRED FOR THE CAMPER/PARTICIPANT. I/WE UNDERSTAND THAT EVERY REASONABLE EFFORT WILL BE MADE BY THE CAMP/HOSPITAL SERVICES TO CONTACT ME/US. THIS IS MY/OUR AUTHORIZATION TO HAVE MEDICAL PERSONNEL AND/OR HOSPITAL STAFFS ADMINISTER MEDICAL OR SURGICAL SERVICES, INCLUDING ANAESTHESIA AND DRUGS TO THE CHILD. I/WE UNDERSTAND THAT ANY COSTS RELATING TO SUCH MEDICAL SERVICES BEING REQUIRED WILL BE MY/OUR RESPONSIBILITY. *

First

Middle

Last