Registration Camper InformationThe person completing this form is*Parent/GuardianSponsoring AgencyName* First Last Birthdate* Date Format: MM slash DD slash YYYY Age*Please enter a number from 6 to 18.Gender*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Attended GLC Before?*YesNoReligious Affiliation*United ChurchAnglican ChurchRoman CatholicNoneParent(s)/Guardian(s) Name(s)* First Last Parent(s) Email*Must be an email you check regularly. Important confirmations and updates will be sent to this address. Parent(s) Phone - Primary Number*Parent(s) Phone - Alternate Number*Emergency Contact* First Last Emergency Contact Phone*Choice of Camp and Choice of RatesChoices of Weeks and Dates*Junior 1 July 5 - 11Junior 2 July 19 - 25Junior 3 August 9 - 15Junior Outdoor Adventure Camp 1 - July 12 - 18Junior Outdoor Adventure Camp 2 - August 2 - 8Scamper Camp (SC) July 26-28Intermediate 1 July 12-18Intermediate 2 August 2-8Intermediate Outdoor Adventure Program 1 - July 5-11Intermediate Outdoor Adventure Program 2 - Aug 8-15Youth Outdoor Skills (YOSC) Camp - July 19-28Senior Youth - August 16-22Rate you will pay*$420 (All week-long camps - 1st week / 1st camper)$360 (All week-long camps - 2nd week / 2nd camper)$265 (Scamper Camp - 3 days - 1st 3 days / 1st Camper)$225 (Scamper Camp - 3 days - 2nd 3 days / 2nd camper)$560 (Youth Outdoor Skills - 1st 10 days / 1st camper)$465 (Youth Outdoor Skillls - 2nd 10 days / 2nd camper)Requesting Geared-to-income (further down on form)Geared to IncomeOur "Geared-to-Income" and "Extended-Payment" Plans guarantee that no child who wishes to attend Golden Lake Camp is ever turned down for financial reasons. Simply complete the section below and send in the form. Our registrar will then register your child for camp, and contact you by phone or email, to work out with you a rate you can afford, or design an "Extended-Payment plan that will work for you. If you have questions, call us at 1-888-659-2267, or email us at firstname.lastname@example.org. Which of the following best describes your family's situation?*We are on Ontario Works or ODSPEmployed but family's income under $25,00 a yearIncome above $25,000/year, but under financial stressPlease briefly explain your situation*How should we contact you?*By phoneBy emailEither is finePLEASE NOTE: When we contact you, all information we receive is confidential.Like to donate to our Camper Subsidy Fund?*Our Camper Subsidy Fund is used to help children who would otherwise be unable to attend camp for financial reasons. A tax receipt is available for all such donations.Yes, I would like to donateSorry, not this yearDonation Amount$10$25$50$75$100Need a receipt for tax purposes?*YesNoOther Helpful InformationDoes this camper have any serious allergies / medical conditions / mental health issues / behavioural issues (A detailed health form will be sent to you later)*No issuesSerious allergiesOther serious medical issuesBehavioural issuesMental health issuesPlease contact us for detailsDetails you would like us to knowAlso inviting a friend?*NoYesLike to be in the same cabin/tent as a friend? (Indicate below--one name only, please.)How many different ways did you hear about Golden Lake camp? Please check all that apply* Family/ friends/ my child's friends Summer camp website www.ottawacamps.com My child's school Social media (Facebook, Twitter, Instagram, etc,) On the radio Our camp's website (www.goldenlakecamp.ca) Google search Our local church Other OtherPaying for your child's attendanceHow do you plan to pay*Please make a selectionCredit CardE-transferPersonal chequeOther arrangementThrough "Geared-to-income"Do you plan to submit the full amount, or a $50 deposit?About refunds: A full refund, minus a $50 administration fee, is available up to two weeks before the child's planned arrival time at camp, or up to the day of arrival, in the event of a confirmed medical or family emergency.I will submit the full amountI will submit a $50 depositI am applying under "Geared-to-income"Deposit ($50)* Price: $ 50.00 CAD Sponsoring Agency InformationName of Agency to be Billed*Agency Contact Name*Agency Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Agency Contact Email* Agency Contact Phone*Prove you're a human...Please enter the text you see below into the box, to prove you're a human.