Science and Technology - Registration Form

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Jul 16th to 20th, 2012
9:00 am - 4:00 pm

Exploring the Universe God Has Made!

Through Chemistry, Physics, Biology, Health Sciences and Technology!

Registration Cost: $100.00 which can be made on the first day of camp.

St. Andrew’s Hespeler Presbyterian Church
73 Queen St. E., Cambridge ON
N3C 2A9
www.standrewshespeler.ca

For grades 1 to 8, Brochures and Registration Forms available at St. Andrew’s Hespeler Presbyterian Church
Tel: 519-658-2652 or email: office@standrewshespeler.ca

Information

Child(ren) Name: *

Please enter the full name of your child(ren)

Parent/Guardian Names: *

Please enter the full name of the Parents/Guardians of the child(ren) above

Street Address:

Please enter your Street Address

City:

Please enter your City

Postal Code:

Please enter your Postal Code

Home Phone:

Please enter your Home Phone number

Alternate Phone:

Please enter your Alternative Phone number

Email:

Please enter your email address

Church Affiliation:

Please describe your Affiliation to the Church

Emergency Information

(If parent/guardian cannot be reached)

Name:

Relation to Child(ren):

Phone Number:

Additional Information

Date of Birth (ddmmyy):

Please enter the Date(s) of Birth of the Child(ren) (ddmmyy)

Grade Completed in June 2012:

Please enter the Grade which the Child(ren) completed in June 2012

Food Allergies:

Please indicate any food allergies the Child(ren) has(have)

Medical Concerns (ADHD, Epilepsy, etc):

Please indicate any other Medical Concerns the Child(ren) has(have)

Pick Up Information

Person Picking Up the Child(ren) each day:

Please enter the name of the person Picking Up the Child(ren) each day

Phone Number:

Please enter the Phone Number of the person picking up the Child(ren) each day

Notice:

- Please note that the child(ren) must bring their own (peanut free) lunch, snacks will be provided.
- Registration payment can be made on the first day of camp.

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