Rosewood Park Alliance Church

Campers First Name

Campers Last Name

Address

Apt. Number

City

Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon

Postal Code

Phone (Residence):

Gender: Male Female

Health Card Number

Age 3 4 5 6 7 8 9 10 11

Birth Date January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

The friend my child would like to be placed with is:

State any special information which the staff should be aware of:
(i.e. health needs, allergies, medication, physical limitations)

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Home Phone

Parent/Guardian Work Phone

Parent/Guardian Email

Parent/Guardian Confirm Email

Please send me info on future family themed events

Emerg Contact #1 (Other than Parent):

Emerg Contact #2 (Other than Parent)

I understand that I am fully responsible for payment of any medical attention
needed for my child(ren), while attending The Park Day Camp. I do not hold
Rosewood Park Alliance Church or The Park Day Camp liable for any accident
or misfortune.

Friend or Family Member

Rosewood Park Church

Sign @ Courtney and Whelan

Brochure Mailing

Community Signs

Return Camper

Other (please state)