Register for Camp Centennial Online

Camper's Information

First Name:

Last Name:

Sex:

Date of Birth:

MM DD YYYY

Address:

City:

Province:

Postal Code:

Telephone:

Email Address:

Parent/Guardian Information

Please enter the child's parent(s)/guardian(s)

Name of Parent(s) / Guardian(s):

Telephone:

Mother's Work #:

Mother's Cell #:

Father's Work #:

Father's Cell #:

Email Address:

Emergency Contact

Emergency Contact:

Relationship:

Telephone:

Work Phone:

Cell Phone:

Camp Choices

Choose a Camp(s):

Munchkins (age 5-6)
Koalas (age 7-8)
Buccaneers (age 9-10)
Trailblazers (age 11+)
*Music Camp (age 7-12)
*Tennis (age 10+)
*Leadership (age 13+)

*Camp only takes place certain weeks

Choose a Date(s):

June 25 - June 29, 2012
July 2 - July 6, 2012
July 9 - July 13, 2012
July 16 - July 20, 2012
July 23 - July 27, 2012
July 30 - Aug 3, 2012
Aug 6 - Aug 10, 2012
Aug 13 - Aug 17, 2012
Aug 20 - Aug 24, 2011

Medical Information

Medicare #:

Expiry Date:

MM DD YYYY

Please check those issues that we should be aware of in your child's situation:

ADD/ADHD
Asthma
Bed wetting
Bronchitis
Convulsions
Chicken pox
Diabetes
Fainting
Dizziness
Headaches
Heart Disease
Hernia
Measles
Menstruation
Mumps
Skin Rash
Sleep Walking
Toothache
Other (please comment below)

Additional Comments:

List Any Allergies:

List any Medication Your Child is Taking:

You will be able to amend this list upon arrival at the camp. Medication brought to camp must be labeled indicating what the medication is for and when it is to be administered.

Waiver

By entering my name below I agree and understand the following:

- I wave all claims against Camp Centennial, the Centennial Outdoor Centre Inc., the City of Moncton and any of its agents in respect to any personal loss or bodily injury resulting from my child’s participation in any Camp Centennial programs offered during the 2012 season.

- All information listed regarding myself and the child that will be attending camp as a result of this registration is up to date and complete. Any change in information is my responsibility and will be updated by contacting Camp Centennial accordingly.

- That my child may be involved in Camp Centennial media, unless I specifically request otherwise.

(Name of Parent/Guardian)

Sponsorship Program

Our sponsorship program is proud to help more young people from around the Moncton community to experience summer camp. If you are interested in helping a child attend camp, please enter an amount that you would like pledge. All funds go directly to sending a kid to camp.

Any sized donation is greatly appreciated by ourselves and the kids you are helping to send to camp!

"Life is what happens while you are making other plans"

Camper's Information

Parent/Guardian Information

Emergency Contact

Camp Choices

Medical Information

Waiver

Sponsorship Program