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Please fill in both sides of this form completely and return to West London Alliance Church with complete fees. Registrations may be mailed to 750 Wonderland Road North London, ON N6H 4K9. Upon receiving your application, an information package and receipt will
be sent to you. If you have any questions concerning WIRED Registration, please contact the church at (519) 471-8716. See you in the Summer!
Camper Information Name: ____________Last First__________________ Gender: M F Mailing Address: ________________________________________________________________________________ City: ________________________________ Date of Birth: ____Year___|___Month___|___Day___ &DPSHU.V(PDLO_________(If applicable) ___________________ Home Church: _______(If applicable)__________ School Camper Attends: __________________________________________________________________________ How did you hear about WIRED? Church Friend/Family Parent/Guardian Name(s): ________________________________________________________________________ Home Number: (____)_________________ Day Phone:(____)_________________ Cell:(____)___________________ Email: _________________________________________________________________________________________ Camper lives with: Father Only Other: ______________________ (If yes, please submit a copy of the court order) Emergency Contact: (If Parent/Guardian cannot be reached) Name: _______________________________________ Phone: (____)_______________________ Relationship to Camper: ______________________________________ Camp Fees ( below fees include al applicable taxes) Registration: $200.00 (Early Bird)
$240.00 (After July 22)
+ $ _____________
($20 each way):
+ $ _____________
= $ _____________
Use of Campers Image: Please sign below to grant WIRED, and West London Alliance Church permission to the reasonable use of camp SLFWXUHVFRQWDLQLQJ\RXUFKLOG.VLPDJHLQIXWXUHSURPRWLRQDOPDWHULDOVEURFKXUHVYLGHRVGLVSOD\V Parent/Guardian Signature: ______________________________________________________ &DPSHU.V1DPH___________First________________________Last____________________________ Health Card #: ______________________________ Version Code: _______________ Check any of the following that apply: Eyeglasses Diabetic Epileptic ADD/ADHD Asthma Does the above named camper have any physical, mental or other conditions or weaknesses that might hinder normal participation in camp activities?_____________________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
(please submit details on separate paper if appropriate)
Current Medications: _____________________________________________________________________________________
*please bring all medications in original bottle/package If your child requires medications every day, and they are not in the original package, they will be held by the nurse, but the nurse will not administer them. It will be the responsibility of your child to come to the nurse and get their medications from her. (The nurse will remind your child if necessary) There will be no medications allowed in the cabins for the safety of all campers, with the exception of asthma inhalers, and epi-pens. Among basic first aid we offer the following OTC medications. Please indicate which of the following medications the Camp Medical Provider may administer. ____ Tylenol Allergies (i.e., food, medication, latex, bees, poison ivy, etc.): *if applicable, please list allergic triggers, symptoms and treatment on separate paper. __________________________________________________________________________________________________________________________________________________________________________  Will Camper carry an EpiPen? West London Al iance Church is not peanut/nut free. We wil honour reasonable requests to help children with serious al ergies self-manage their condition. You have my permission for the above named child to attend WIRED and participate in all activities on the property of Riverview Bible Camp. The parents/guardians submitting this application are those having legal custody over the child. The Camp Directors reserve the right to dismiss any child who in his/her opinion is a hazard to the safety and rights of others or who appears to have rejected the reasonable expectations of the camp. The parent or guardian hereby agrees to reimburse the Camp for any property damage caused by the camper. While every precaution shall be taken to ensure the good welfare and protection of the camper, WIRED, West London Alliance Church, its staff and board members, employees and volunteers or facilities outside the church property are hereby released from any and all liability in the event of any accident, illness or misfortune that may occur to the camper. I hereby authorize WIRED personnel to handle any medical problem with my child during his/her stay at camp. After making every reasonable effort to contact parents/guardians and emergency contacts named in this registration, permission is hereby given to the physician selected by Camp Directors to provide proper treatment. This may include being removed from the site to a local hospital. The parent or guardian is responsible for any additional expense that might arise from such a service. There will be no reduction of fees for campers arriving late, leaving early, or expelled through disciplinary action. I have read the WIRED brochure and application form, have provided true and accurate information and am in full agreement with the conditions of enrol ment. All information collected in this registration will be used only by WIRED for the specific purpose of providing an excellent summer experience for your child. _  ____________________ ________________________________________ _____________________________________ Date Parent/Guardian Signature Parent/Guardian Name (Please Print) It is understood that by submitting a camp registration for your son or daughter that you are providing consent for West London Al iance Church to col ect and retain information necessary to provide a safe, healthy, fun camp experience for your child and to col ect payment for the same.

Source: http://www.wlacamps.org/files/westlondonalliancechurch/WIRED%20Registration%20Form%202012.pdf