Register me for Ocean Commotion!

VBC July 4 8/16

Childs name
______________________________________________________________________________________
Gender: Male / Female

Birthdate _______/_______/_______ Grade completed _______________

Address _____________________________________ City _______________________ Prov. _______

Postal Code ______________
Parents/Guardian______________________________________________
Home phone _________________________ Work phone_______________________
Cell phone________________________ Email __________________________
Emergency contact _______________________________________________________________________
Relationship to child ____________________________________________ Phone ____________________
Name of home church (If any) ______________________________________________________________
Childs Tshirt size: __________
Food allergies Y___ N___
List____________________________________________________________________________________

Medical or other concerns Y___ N___

Explain___________________________________________________________________
Is there anything else which we should be aware of, which will help us to make your child comfortable and more
effectively teach him/her? (For example, learning disabilities .)
________________________________________________________________________________
May we put your childs photo on the church website? ________ Yes
How did you hear about us? Ad in the Cosmos Guide _____

________ No

Online at Uxbridge Town Talk _____

Online at Durham Region site ______ Friend ______ Poster _____ Other __________________

PLEASE DONT FORGET TO FILL IN THE OTHER SIDE OF THIS FORM

Please note:

The offsite waiver (reverse) is so that we can take your child/ren to the neighbouring park, and to Forsythes
Farm.
Please send a bag lunch, which is nut free, with your child. The Camp is NOT A NUT FREE
ENVIRONMENT.