Youth Camp 3 Registration

* Indicates required field

Name *

First

Last

Choose One *

Female Male

Date of Birth (m/d/y) *

Age *

Mailing Address *

Town/City *

Postal Code *

Phone Number *

Email *

Parent/Guardian Name *

Parent/Guardian Phone Number *

Can we send you information about future camp events? *

Yes No

Cabin-Mate Request *

FIRST Choice of Camper Weeks: *

Youth Camp 1 - Ages 8-13 - July 9-14 Youth Camp 2 - Ages 8-13 - July 16-21 Youth Camp 3 - Ages 8-13 - July 23-28

SECOND Choice of Camper Weeks: *

Youth Camp 1 - Ages 8-13 - July 9-14 Youth Camp 2 - Ages 8-13 - July 16-21 Youth Camp 3 - Ages 8-13 - July 23-28

T-Shirt Size *

Medical & Emergency Information

Alternate Contact In Case Of Emergency *

Alternate Contact Phone Number *

Family Doctor *

Dr. Phone Number *

Health Card # *

Province *

Expiry Date *

Does camper carry an EpiPen? *

Yes No

If yes to Epi-Pen, where does camper carry it? *

Expiry Date of Epi-Pen *

Has the camper had a Tetanus Shot? *

Yes No

Date of Last Tetanus Shot *

Any Medical Concerns, Bed Wetting, Allergies, Epilepsy, Mental Health Concerns, or Physical Limitations: *

The Following Is To Be Completed By Parents/Guardians If Child Is Under 18

Liability Release & Parent/Guardian Consent

I hereby waive, release, and discharge any and all claims for damages regarding personal injury, loss or damage which may hereafter occur to me as a result of participating in activities and transportation for camp programming. This release discharges in advance Camp Lemieux, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above.

I agree to observe safety procedures and practices for camp activities at all times. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing these risks, I hereby assume these risks.

It is further understood and agreed that this waiver, release, and assumption of risk is binding on my heirs and assignees. As parent(s)/guardian(s), I give consent for the registered camper above to participate in all camp activities, and I execute this liability release on their behalf, if under 18 years, as indicated by my response below:

Liability Release & Parent/Guardian Consent *

YES - I agree and consent to the above Liability Release

Medical Care Consent

Camp Lemieux requires parent or guardian consent that gives permission to the official in charge, or his/her deputy, to make arrangements for the child in the event of necessary medical attention, without the parent(s)/guardian(s) prior approval. Parent(s)/Guardian(s) will be notified by the quickest means possible if this authority is exercised. I hereby give consent as legal parent(s)/guardian(s) for necessary medical attention for my child while attending Camp Lemieux as indicated by my response below:

Medical Care Consent *

YES - I consent to the above Medical Care Plan for my child

Photo Release

I understand that my child's photo may be taken for promotional purposes, including brochures, website and social media, and I waive the right to inspect or approve the photo if used for such purposes. I acknowledge that these photos are the property of the photographer and I hereby give consent as legal parent(s)/guardian(s) for them to be used for Camp Lemieux promotional purposes as indicated by my response below:

Photo Release *

YES - I consent to the above Photo Release NO - I do not consent to the above Photo Release

Drop Off & Pick Up Of Campers Under 18

Drop Off Plan *

I fully acknowledge that whomever is delivering my child to Camp Lemieux MUST SIGN IN at registration upon arrival

I hereby declare, as parent(s)/guardian(s) of registered camper above, that the pick up plan will be as indicated by my response below:

Pick Up Plan *

I will personally be picking up my child from Camp Arrangements have been made for someone other than myself to pick up my child from Camp

The following MUST BE COMPLETED if you are not picking up your child personally:

Name *

Cell Phone Number *

Relationship To Camper *

Work Phone Number *

Additional Comments *

Methods of Payment

My chosen method of payment is: *

PayPal accepts all major credit cards from Visa, Mastercard, American Express and Discover.
You do not need a personal PayPal account to pay for your camper registration
using PayPal through our online store.

If you are unable to process your payment through PayPal at our online store,
mail a cheque payable to Camp Lemieux to:
Camp Lemieux
c/o Jim Dietrich
Box 68
Mendham, SK S0N 1P0

Submit For Payment

Medication Form

All those requiring medication administered while at camp will need to complete an additional Medication Form. All medications, along with completed Medication Forms, must be turned over to the First Aid Personnel on Registration day.