2014 Family Camp Registration

2014 Salem Acres Family Camp
August 1-4, 2014

Payment is required during this online registration. Once you submit this form, you will be redirected to PayPal to make the payment. You do not need a PayPal account to make the payment, just a valid credit card. Your application will only be submitted to us if your payment is authorized. Please submit one application per family unit.
Required fields are indicated by *
PRIMARY CAMPER
First Name	*
Last Name	*
Mailing Address	*
City/Town	*
Province	*
Postal Code	*
Email Address	*
Home Phone #	*
Cell Phone #
Daytime Phone #
Your Age	*
Your Gender	*	Male Female
Your Provincial Health Insurance #	*
Please indicate the number of people you will be bringing with you, including adults, children (ages 3-18), children (ages 2 and under).
Adults	*
Children including guests (ages 3-18)	*
Children (ages 2 and under)	*

OTHER FAMILY MEMBERS (or guests 3-18)
1. Name
Age
Gender		Male Female
Provincial Health Insurance #
2. Name
Age
Gender		Male Female
Provincial Health Insurance #
3. Name
Age
Gender		Male Female
Provincial Health Insurance #
4. Name
Age
Gender		Male Female
Provincial Health Insurance #
5. Name
Age
Gender		Male Female
Provincial Health Insurance #
6. Name
Age
Gender		Male Female
Provincial Health Insurance #
For Guests (ages 3-18), please provide us with Parent/Guardian information, including: Full Name, Address, Phone Number, and Email Address.
Note: If you have an RV and are willing and able to come with it for accommodation, please do so. Also, please feel free to come with tents if you so desire. Limited RV service locations available on the property. Non-serviced locations available for many more RVs or tents. Please indicate below if applicable.
1. Will you be coming with an RV or tent?	*	Yes No
2. Do you require a serviced location?		Yes No
Please indicate if you will be coming for partial weekend and what days you will be here for
Please indicate if you are coming for the daytime only and will not need accommodation	*	Yes No

EMERGENCY CONTACT INFORMATION
In case of an emergency, please provide us with the person we should contact if we are unable to reach you.

Full Name	*
Phone #	*
Additional Phone #

MEDICAL INFORMATION
By name of participant, please tell us about any existing medical conditions that any member of the family/guest coming to camp has.	*
List by name of participant any medications will any family member/guest be taking while at camp.	*
List by name of participant if any family member/guest has allergies. If so, please tell us about who has them and how they are treated.	*
Do you give SABC and its staff permission to administer non- prescription medications (such as Tylenol, Gravol, cough medicine, Benadryl, etc.) according to the recommended dosage, when needed?	*	Yes No
Is there any other information that you think we need to know?	*

REGISTRATION FEES
Children 2 and under are free.
Please choose the registration your family qualifies for.		Adult Single - $100 Adult Couple - $200.00 Family with 1 Child - $250.00 Family with 2 or more Children - $300
TOTAL REGISTRATION FEES:

CONSENT
By filling in your name below, submitting this form, sending the child to SABC or attending a camp, you agree to the following statements:
1. Medical - I give SABC and its staff members the permission to proceed with emergency medical treatment in the event they cannot contact me in the time available. Salem Acres staff/personnel may authorize medical personnel to proceed with treatment.
2. Liability - I will not hold SABC, its staff members or volunteers liable for any accident in which loss or damages occur. I waive the right to proceed with any and all actions against SABC, its staff and volunteers for any incident, including those caused by negligence.
3. Use of Photos – I give SABC permission to use photos taken during camp by SABC staff and volunteers for promotional purposes.
Responsible Family Member Consent
Do you give Consent?	*	Yes
Full Name	*
Today's Date	*