IGNITE! Retreat at Fircom
Registration Form
Please fill in this section with your information.
There are additional sections to enter information for those travelling with you. Email youth@canadianmemorial.org with any questions.
General Information
Name:
Your answer
Date of Birth
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/
DD
/
YYYY
E-mail Address:
Your answer
Please re-type your e-mail address:
Your answer
Phone Number:
Your answer
Address:
Your answer
Health Card Number
Your answer
Dietary Restrictions
Required
Intolerances to Food
Your answer
Health Information
All information on this form will be kept confidential. This info is required primarily in case of an emergency.
Allergies
Please indicate severity and triggers (airborne, contact, or ingestion). In the case of severe allergy please provide a personal emergency management plan and history of previous reactions.
Your answer
Medication:
Please list any medications and if assistance is needed.
Your answer
Please list any other medical concerns:
Please include history of any major injuries.
Your answer
Emergency Contact Information
Please provide two people to contact as well as their phone numbers and their relationship to you.
Your answer
Accommodations
We hope to ensure that all campers are comfortable. We will do our best to give you your first or second choice of accommodations. Find out more about Fircom's accommodations here:
http://fircom.ca/accommodations/quick-facts/
Accomodations: First Choice
Accomodations: Second Choice
Accomodations: Third Choice
Accomodations: Fourth Choice
Accomodations: Fifth Choice
If registering for more than one person, can your party/family be split? If yes, please specify:
Your answer
Please specify any accommodation needs due to mobility limitations, health concerns, young children, sleep disorders, bug allergies etc.
Your answer
Is there anything else you would like us to know when we are finalizing the sleeping arrangements?
Your answer
Are there any other people you would like to be roomed with?
Your answer
Travel Arrangements
Which of the following Friday departure times work for you?
Please check all that apply
Required
On Sunday, the water taxis leave between 12 and 2pm.
Do we have your permission to share your e-mail address with other attendees for the purposes of arranging carpooling?
Program Choices
Throughout the weekend there will be programs with restricted capacity. We can offer additional sessions if there is sufficient interest.
Please indicate which programs you and your family would be most interested in:
Are there any others activities you'd like to participate in?
Your answer
How would you like to help out during the event?
Payment
How much are you able to afford for this weekend retreat?
The basic cost of this event is $230 per adult, and $190 per child over the age of 3. This covers the cost of accommodations, water taxi, food and programs. We ask that you pay what you can afford, in the range of $150-$310 per person. No one will be turned away for lack of funds. Please contact youth@canadianmemorial.org if funds are a barrier.
Your answer
Would you like to donate to our Camp Fircom Bursary?
The cost of this event is prohibitive for many of our congregation members. If you are able, please consider donating an extra $20, $50, $100 or $200 to help others join in on the fun!
Are you registering another family member?
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