2010 Camp Reservation & Safety Information Form

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Camper's Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Gender * Male Female
Birth Date * / MM / DD YYYY
Age *
School *

For upcoming year
Home Phone * - (###) - ### ####
Parent Email *
Select Camp Dates * Beginner: Fundamentals (July 5-9) Intermediate: Going Further (July 12-16) Advanced Advanced: Training (July 19-23) Beginner: Fundamentals (July 26-30) Intermediate: Going Further (Aug 2-6) Advanced Advanced: Training (Aug 9-13)
Guardian's Name * First Last
Cell Phone - (###) - ### ####
Employer
Work Phone - (###) - ### ####
Emergency Contact Name * First Last
Relationship *
Emergency Contact Phone * - (###) - ### ####
Camper’s Physician
Physician Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Physician Phone - (###) - ### ####
Persons Authorized to pick-up child *
Persons NEVER Authorized to pick-up child
Payment Method * Cheque Cash (please do not mail)
Make cheques payable to the Funday Skateboard Association, 87 Germain Street, Saint John, NB, E2L 2E8
Click here for terms and conditions * I agree to to these terms and conditions I do NOT agree to to these terms and conditions