CFC-Youth Mississauga West Chapter

PROCLAIM
CAMP

$

Nov. 16-18, 2012
Countryside Camp at
Cambridge, ON

40 fee

covers meals,
transpo, materials
and accommodations

$

"MY GOD, THAT I MAY PROCLAIM YOUR MIGHT TO ALL
THE GENERATIONS YET TO COME" PSALMS 71:18

60

and

package

$

40

and

20
Limited
$

CAMP PROCLAIM SHIRT
$

10 FREE!!!

General Info
Name: ____________________________________________________________________ Nickname:_______________________
(Family name)
(Given name)
(Middle Initial)
Address: ___________________________________________________________________________________________________
______________________________________________________________________ Postal Code:________________________
Home Phone: ______________________ Cellphone No.: ______________________ E‐mail: _____________________________
Birthday :__________________________ (MM/DD/YEAR) Twitter Account : _________________________________________

Allergies: ________________________________________ OHIP #: _________________________
Persons to notify in case of emergency : (Name / Relationship and Cellphone Number)

_________________________________________________________________________________
Diet Restrictions: _________________________________________________________________
Camp Participant You Personally Invited: ___________________ and ______________________

Release of Liability

: I acknowledge that there are certain risks involved in said activities. I release CFC-Youth, its
associates, volunteers, and employees of all responsibilities for any injuries to body, or property which may occur to me during the
course of these activities. In the event of an emergency in which I, or the alternate contact, can not be reached, I authorize the adult
leaders to make medical decisions for me, and I further agree to indemnify and hold harmless CFC-Youth arising from my participation
in activities or as a result of my injury or illness during such activities. I have read the waiver form and I am fully aware of its contents.
I, ____________________________, agree to the terms of this waiver, and have full consent and permission from (Name of Parent /
Legal Guardian) ______________________ who have read and is in full agreement with this waiver of liability.

_______________________________
Signature of Parent / Legal Guardian

FOR ADMIN USE ONLY:

_____________________________
Signature of Youth Camp Servant

Paid (Y/N) ________________

_____________________________
Date Signed

Deposit (Y/N) ___________ Need a Ride (Y/N) _______

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