ROAD TRIP SUMMER CAMP REGISTRATION – WYNCHEMNA

Name of Student (exactly as passport)(*)

Please be sure the name you enter here is the student's exact name as it is shown in his or her passport.

Gender(*)

BoyGirl

Date of Birth(*)

Day01020304050607080910111213141516171819202122232425262728293031 / MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / Year1990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017

Special Information

Please provide any details about your child that we should know about - allergies, disabilities, medications, or other important information.

Current School

How did you hear about us?

Attended beforeFriendsInternet searchESL teacherESL schoolTravel agentAgentNewspaperRadioFacebookTelevision

Parent or Guardian Full Name(*)

Parent/Guardian Address(*)

Please enter your full mailing address. This might be required for a visa if required.

Parent/Guardian Job Title

This might be required for visa purposes if required.

Parent/Guardian Employer

This might be required for visa purposes.

Home Phone(*)

Mobile/Cell Phone

Email(*)

My child wants to register for the following course(*)

5 week - Calgary July 4 to Vancouver August 74 week - Calgary July 11 to Vancouver August 7

My child wants instruction in:(*)

EnglishEnglish and French

How many years has your child studied English(*)

How many years has your child studied French?

Child's swimming ability(*)

Non-SwimmerBeginner SwimmerStrong Swimmer

I understand that Wynchemna reserves the right to cancel or modify any programme or programmes listed in the brochure because of an insufficient number of participants or for any other reason beyond its control. In such a case, written notification of cancellation will be sent out and the fees will be refunded.(*)

Yes

I understand that Wynchemna reserves the right to withdraw participants whose behavior is likely to affect the smooth operation of the programme or adversely affect the enjoyment or safety of other participants. Wynchemna will be under no liability to such persons. If a child has to be sent home on disciplinary grounds, the parents will be required to pay for any costs incurred.(*)

Yes

I give permission to the Wynchemna Instructor to sign a waiver-form for my child.(*)

Yes

I understand and permit that my child may have his or her photograph taken, and that these photographs may be used for advertising or other purposes by Wynchemna (for example, in brochures or on its website).

Yes