Winter Camp Registration

Parent or Guardian
Parent/Guardian Name*
First Last
Address*
Street Address City Postal Code
Phone*
Email*
Relationship to child*
Emergency Contact 1
Name*
Contact Number*
Relationship*
Emergency Contact 2
Name*
Contact Number*
Relationship*
Child Attending
Child Name*
First Last
Name Goes By
Birthdate*
Pronoun
Medical Number
Family Doctor
Allergies/Medication
Can they self administrator meds?*
- Yes
- No
- N/A
Medical Condition/Exceptional Behaviours:
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Registration Cost
Total
$ 0.00 CAD
Payment Method*
Your spot won't be guaranteed until full payment has been received.
- I'll pay online now using my credit card
- I'll pay cash or cheque at the LRCC

Credit Card

Cardholder Name

Card Details

Parent or Guardian