Registration Form – General informations Last name : First name

CAMP D’IMMERSION CULTURELLE
July 6th to 17th and July 20th to 31th 2015
Terre-des-jeunes, Alexandria
Registration Form – General informations
Last name :
First name :
Date of birth :
(dd/mm/yyyy)
Health card # :
Main address :
Postal code :
City / Province
Home phone #
School attended :
Current grade :
Homeroom teacher’s name :
Mothers name :
Fathers name :
(last and first)
(last and first)
Email :
Email :
Work phone # :
Work phone # :
Cell phone # :
Cell phone # :
In case of emergency, the camp employees are allowed to take all the necessary arrangements to help
my child.
Yes
No
Emergency contact other than the parents
Contact 1 :
Contact 2
(last and first name)
(last and first name)
Relationship :
Phone # :
Relationship :
Phone # :
Phone # :
Phone # :
Medical information : allergies, medications, etc.
Other persons authorized to pick up children other than the
parents
Camp choice
Block
Block 2
July 6 to 17, 2015
Please prepare a check in the amount of
240$ dated June 22, 2015
July 20 to 31, 2015
Please prepare a check in the amount of
240$ dated June 22, 2015
the parent who made the registration:
date of registration (mm/jj/aaaa) :
/
Signature : _______________________________________________________________________
/
CAMP D’IMMERSION
CULTURELLE
Choix de camp
Block 1
Block 2
1er
ENFANT
2e
3e
RÉSÉRVÉ AUX FINANCES
Mère
Père
Type de famille
monoparentale
Dépôt 50$
Montant
# de chèque
$
Montant
# de chèque
$
# de chèque
$
Montant
À la mère
Au père
séparée
Paiement du camp d’été
Montant
nucléaire
Reçu d’impôts
reconstitué
# de chèque
Date d’expiration :
Notes
BDD
$
Réservé à l’administration
Inscription
Membre 15$
Finances
BDD
# chèque
PARENTAL PERMISSION- Publishing name and picture of your child
To promote the Camp d’immersion culturelle, we ask your permission to publish the name or picture of your child in following
documents. Please initialise :
Arts and crafts (published inside the school)
Pictures
CEPEO website
Videos and promotional activities
Flyers and information sheets
Yes, I give permission for my child to be photographed or have his name published by the CEPEO in the documents
mentionned above. No other personnal information will be published without my consent. I acknowledge, by giving consent,
that the pictures and my child’s name might become public and visible.
I do not want my child to be photographed or have his name published by the CEPEO.
Signature : _______________________________________________________________________