Girls LEAD London

Girls LEAD London 2012 Registration Form

Camper Info
*Camper Name
*Grade entering in September 2012
*Birth Date	(Month/Day/Year)
Address

Shirt Size
Allergies, medical and dietary concerns

Additional comments, behavioral concerns

*Please indicate which camp session you are registering for: Junior Camp (Grades 3-4) Section B (July 16th 2012-July 27th 2012) Intermediate Camp (Grades 5-6) Section A (July 3rd 2012-July 13th 2012) Intermediate Camp (Grades 5-6) Section C (July 30th 2012-August 10th 2012) Senior Camp (Grades 7-8) Section B (July 16th 2012-July 27th 2012) /div> Senior Camp (Grades 7-8) Section C (July 30th 2012-August 10th 2012)
Parent / Guardian Info
*Name
*Relationship to Camper
Phone Number
Alternate Phone Number
Primary E-mail
Emergency Contact Info
*First Emergency Contact
*Relationship to Camper
*Phone Number
Second Emergency Contact
Relationship to Camper
Phone Number
*Parent / Guardian Consent
I grant my child permission to participate in Brescia University College's Girls LEAD Summer Camp Program and all activities therein. In the event of illness or injury affecting the named camper, I authorize Brescia University College to provide or cause to be provided such medical services as it deems appropriate. I also agree to allow Brescia University College to reproduce the likeness of my child (photo, video, etc.) in promotional materials or publications. I agree to the procedures and policies of the camp as outlined at: http://www.brescia.uwo.ca/about/summer_camps/girls_lead_london/index.html
Camp Fees are due upon registration. See Below.
Payment info
Registration for each session is two full weeks for $395. Payment can be sent to or dropped off at the Business Office in Mother St. James Building at the address below. Payment via Visa or MasterCard Print and fill out this form for payment via Visa, MasterCard. Once the form is complete, it can be faxed to 519-858-5116 or mailed in to the address below. Debit and cheques payable to Brescia University College are also accepted.
I would like to make a donation to support another child who may not otherwise have the opportunity to come to girlsLEAD.
Amount
*Registration cannot be completed without camp registration fees payment.*

Girls LEAD London

Girls LEAD London 2012 Registration Form

Camper Info

Parent / Guardian Info

Emergency Contact Info

*Parent / Guardian Consent

Payment info

Payment via Visa or MasterCard

Print and fill out this form for payment via Visa, MasterCard. Once the form is complete, it can be faxed to 519-858-5116 or mailed in to the address below. Debit and cheques payable to Brescia University College are also accepted.

Registration cannot be completed without camp registration fees payment.

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