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WELCOME | PROGRAM | STAFF
 
Registrants for the adult program are only required to fill out the fields that are marked with a red asterisk "*"

CAMPER INFORMATION
*First Name
 *Last Name
 Middle Name
AKA/Nickname
*
*
*Birthdate
 School Grade completed prior to camp:
Age at the start of camp *Will the camper have their Birthday while at camp?
*Home Address
 *City
 *Province/State
*Postal/ZIP Code
 *Country
 *Camper's Email
*Home Phone
 Native/Primary Language Spoken
 Second Language
If English is their second language, what level are they at:

PARENT/GUARDIAN INFORMATION
Camper lives with:
Mother's Information:
First Name
Last Name
Home Phone
Work Phone
Cell Phone
Email
Father's Information:
First Name
Last Name
Home Phone
Work Phone
Cell Phone
Email
(If different from camper's home address) Mailing Address of :
Address City
Postal Code/Zip Country
Guardian's First Name
 Last Name
 Home Phone
Work Phone
 Cell Phone
 Email
Are you working with a Child Care Organization or other Support Program?
If YES, Name of Organization
 Contact Name
Work Phone
 Pertinent Details
Specify any other(s) authorized to visit or pick-up the camper from Safari Zoo Camp (photo ID will be required):
First Name
Last Name
Relation to Camper
First Name
Last Name
Relation to Camper

EMERGENCY CONTACT INFORMATION
To be used ONLY if a parent or legal guardian can not be contacted during a serious illness or emergency:
*First Name
*Home Phone
*Last Name
*Work Phone
*Relation to Camper
*Cell Phone
*Email

PROGRAM INFORMATION
SAFARI CLUB: Ages 6-8
  
 
KIDS CAMP: Ages 9-12
TEEN CAMP: Ages 13-17
*ADULT CAMP: Ages 18+
Full (wait list)-Session 5, July 27 - August 2
Alternative Session (2nd choice):
Try to ensure this camper is in the same bunkhouse as the following camper (write full name):
1. 2.
*Conditions that apply: . mutual request . gender and age appropriate . available space

CAMPER PREFERENCES AND OTHER INFORMATION
*Permission to publish the campers photo in a newsletter, website and/or advertisement:
*T-shirt Size:
*Preferred accommodations (adult program only):
*What special interests, hobbies or talents does the camper have?
*How did you hear about Zoo Camp:



MEDICAL INFORMATION
*Family Physician-Full Name
*Office Phone
Last Examination
HEALTH INSURANCE: Health Insurance of some type is mandatory. Campers that are Canadian residents are required to submit a clear photocopy of their Health Insurance Card. All other campers that reside outside of "Canada" are required to submit a copy of their Health Insurance Plan. * Non-Canadian residents are required to pay any medical expenses directly, which is later reimbursed by the health insurance company.

*Canadian Citizens
Health Card #
Version Code
Valid Until
Province
*International Residents
Name of Insurance Company
Policy #
Emergency Contact Phone#
 

ALLERGIES AND REACTIONS:
Drugs
*Food (Also note dietary restrictions or choices, for example- vegetarian, lacose intolerant, etc):
*Animals (Including insect stings/bites):
Seasonal Allergies
*Other
Camper Carries:
If the camper has had an anaphylactic reaction, advise when and severity:
IMMUNIZATIONS:
 

PAST HISTORY OF COMMUNICABLE DISEASES AND APPROXIMATE DATES:

OTHER EMOTIONAL, HEALTH OR SOCIAL ISSUES:
 
Does the camper require:

Is there currently any form of treatment/medication for any illness, operation or injury?
If YES, specify necessary details/treatment:

*Have there been any illnesses, operations or injuries in the past that may limit or affect participation in any of the Safari Zoo Camp activities?

If YES, please specify:
Has the camper received or is receiving psychological, group counselling or psychiatric help?
If YES, please provide any necessary information:
FOR FEMALE PARTICIPANTS:
Has she menstruated?
If NO, has she been told about it?
Special Considerations
If YES, is the menstrual history normal?
MEDICATION TO BE GIVEN AT CAMP: All medication must be submitted to Safari Zoo Camp in its original container, clearly labeled by a pharmacist or physician with the medications name and instructions.
 
Medication Name
Dosage
Time(s)
Reason
1
2
3
4
Does the camper take any medications that will NOT be sent to camp?
If YES, explain if necessary:
Permission granted to give the camper the following nonprescription medication if deemed necessary:

PAYMENT

Online payment is not yet available. The requested Session(s) will be reserved upon receipt of this online registration form, but to secure enrollment, the deposit ($100.00 per camper per week) must be received by Safari Zoo Camp within 3 weeks. Full payment is due by June 1. Only Canadian Funds accepted. Prices calculated below will be subject to verification.

How many sessions will the camper be attending?
  *

Weekend Supervision: For those staying more than one week consecutively, please specify how many weekends (between sessions) that the camper will require supervision:

*Transportation Service:

*Discounts:
Registrations received prior to March 31

Total
All applicable taxes included.
Deposit:
* Must be received within 3 weeks to secure enrollement.
Balance:
* Due by June 1

*Options:
*
*
*
*

Before submitting, please check the form to ensure all the necessary information has been entered correctly. Thank you.

WELCOME | PROGRAM | STAFF | ANIMALS | SAFARI
REGISTER | FACILITY | PHOTOS | CAMPERS | CONTACT

3667 Concession Road 6, P.O. Box 370, Orono, Ontario, L0B 1M0, Canada
phone: (905)983-8217 | fax: (905)983-9858
http://www.zoocamp.com | email: info@zoocamp.com
©Copyright 2000-2009, Jungle Cat World®, Safari Zoo Camp®. All rights