2014 Salem Acres Summer Camps Please submit a registration form for each camper and for each camp he or she will be attending. 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. If you are unable to register online, please email the registrar . If you are unable to pay the full registration fee, please email the registrar and request a "2014 Salem Acres Camp Scholarship Registration" form. BUS SERVICE IS PROVIDED FOR : SOUTH CALGARY-$30.00 per camper, $40.00 per Family NORTH CALGARY-$30.00 per camper, $40.00 per Family INNISFAIL-$20.00 per camper, $30.00 per Family 2014 CAMP SELECTION * Sr. Teen Camp: June 29 - July 4 (Ages 15 to 18) Kids Kamp I: July 6 - 11 (Ages 7 to 10) Girls Camp: July 13-18 (Ages 11 to 13) Boys Adventure Camp: July 20-25 (Ages 11 to 13) Jr. Teen Camp: July 27 - Aug 1 (Ages 13 to 15) Kids Kamp II: Aug 10-15 (Ages 7 to 10) CAMPER'S PERSONAL INFORMATION First Name * Last Name * Mailing Address * City/Town * Airdrie Big Valley Blackfalds Calgary Carstairs Coalhurst Cochrane Delburne Didsbury Edmonton Elnora Erskine High River Langdon Linden Lousana Okotoks Pine Lake Red Deer Spruce Grove Stettler Strathmore Three Hills Trochu Wimborne Other If you selected "Other" above, please type in the City/Town: Province * AB BC SK Other If you selected "Other" above, please type in the Province Postal Code Home Phone # * Cell Phone # Daytime Phone # Email Address * Gender * Male Female Birthdate Grade (entering in fall 2014) * 1 2 3 4 5 6 7 8 9 10 11 12 Post-secondary Age camper will be on of December 31, 2014 * The use of a life jacket are included in the camp fee. If you choose to send your own life jacket, please mark it clearly. There is no change in fee. A T-Shirt is included in all registrations. Please provide us with a size for the camper. Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large Home Church Have you attended a Salem Acres camp before ? * Yes No Did a friend invite you? If "Yes", enter their full name Do you have a request for a Cabin-Mate? If so, please enter their full name. PARENT/GUARDIAN INFORMATION If the camper is over 18, fill the required fields with NA First Name * Last Name * Relationship to camper * Email Address * Contact Information the same as the camper? * Yes (Skip the following contact info) No (Fill in the following contact info) Mailing Address City/Town Airdrie Big Valley Blackfalds Calgary Carstairs Coalhurst Cochrane Delburne Didsbury Edmonton Elnora Erskine High River Langdon Linden Lousana Okotoks Pine Lake Red Deer Spruce Grove Stettler Strathmore Three Hills Trochu Wimborne Other If you selected "Other" above, please enter in the City/Town: Province AB BC SK Other If you selected "Other" above, please type in the Province Postal Code Home Phone # Cell Phone # Other Phone #   EMERGENCY CONTACT INFORMATION In case of an emergency, provide the name of the person we should contact if the Parent/Guardian is unreachable: Full Name * Relationship to camper * Main Phone # * Alternate Phone # MEDICAL INFORMATION Provincial Health Insurance # * Will the camper be taking any medication while at camp? * Yes No If yes, please list the medication, dosage and frequency. Does the camper have any allergies or has the camper ever reacted to any animals, foods, medications, environmental products or anything else? * Yes No If yes, please describe the reaction and how you treat the allergies at home. Do you give antihistamines? If yes, how often? Does the camper have any type of disability (mental, emotional or physical) that could affect his/her degree of participation in any activity? * Yes No If yes, please describe. NEW POLICY: We will no longer be stocking medication for minors. Please provide any medications (including Tylenol, Ibuprofen, etc) for your child that you anticipate they may need while at camp in a resealable bag with the Child's Name, Parent/Guardian Name and Emergency Phone Number. All medications in this bag must be in the original packaging with appropriate dosage for their age/size. Dosage other than what is recommended on the packaging must be indicated in writing, signed by the parent/guardian and included in the bag. We are no longer able to administer ANY medication to your child that is not in this bag. If any medication is taken on a regular or semi-regular basis, the parent/guardian is responsible for ensuring that the appropriate medication is sent with the camper in a resealable bag, with the Child's Name, Parent/Guardian Name and Emergency Phone Number, and in the original prescription packaging. ALL medication is to be given to the camp nurse with written instructions upon arrival at camp. Medication of any kind is NOT permitted to stay with the camper while they are at Salem Acres. All medication should be picked up from the camp nurse by a parent/guardian on the last day of camp when you collect your child. Are immunization shots (e.g., tetanus) up to date? * Yes No Any additional information you would like to share regarding immunizations? Is there any history of disease (e.g., Hepatitis C)? * Yes No If yes, please provide details: Does the camper suffer from asthma? If yes, please send all the appropriate medication with the camper. * Yes No Is there any other information we need to know about the camper?   REGISTRATION FEES Are you sending more then 3 campers from the same family to Salem Acres this year? * Yes No Please provide the names of other children, and the camp they are attending. Please indicate the registration fee your family qualifies for. * $225.00 - Regular Registration - $200 - Family Rate Registration (Available to families sending 3 or more campers) Bus Service - To and From Salem Acres $30.00 - South Calgary - Regular Rate $40.00 - South Calgary - Summer Family Rate $30.00 - North Calgary - Regular Rate $40.00 - North Calgary - Summer Family Rate $20.00 - Innisfail - Regular Rate $30.00 - Innisfail - Summer Family Rate   Tuck Shop will be open once per day to purchase snacks/merchandise. Food purchases are limited to $3/day. Any amount remaining on the last day of camp, not spent/refunded will be donated to Salem Acres. $25.00 No, Thank-you Donation Section - Salem Acres Bible Camp strives to offer a Christian Camp experience at well below our actual cost. We depend on donations to fully operate and maintain the camp, and to upgrade our facilities. Please consider an additional donation to help us offer the best we can to the kids who come or consider sponsoring another child's registration fee! A tax receipt will be issued for your donation. Donation amount (Please use a number with decimal places.) OR I would like to sponsor a child-in-need for a camp. (A Tax-Receipt will be sent for all donations) 1 - $225.00 2 - $450.00 3 - $675.00 No, thank-you TOTAL FEES DUE *   CONSENT By filling in your name below, submitting this form, and sending the child to Salem Acres to attend a camp, you agree to the following statements: 1. Medical - I give Salem Acres and its staff members the permission to proceed with emergency medical treatment. I also authorize medical personnel to proceed with emergency treatment. 2. Use of Photos – I give Salem Acres permission to use photos taken during camp by Salem Acres staff and volunteers for promotional purposes. 3. Liability - I will not hold Salem Acres, 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 Salem Acres, its staff and volunteers for any incident, including those caused by negligence on our part. Do you give Consent? * Yes I would like to receive updates from Salem Acres and email reminders about registration next year. * Yes No, Thank-you Parent/Guardian Consent or Camper Consent (if the camper is 18 or older) Full Name * Today's Date * NOTE: If this form turns red after clicking on "Proceed to Payment", please scroll up and fill in all "Required Fields".