M.A.D. Camp 2023 Registration
Please answer the following questions so we can better prepare for the needs of all campers. Please be advised that all information is kept in strictest confidence. MDAM adheres to the guidelines as outlined in FIPPA, PHIA and PIPEDA. Registrations will be reviewed by Youth Coordinator and Executive Director for final approval.
Camper Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Manitoba Health Number (9 digits)
Parent/Guardian Name (s)
*
First Name
Last Name
Parent/Guardian Name (s)
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Which week of M.A.D. Camp are you interested in attending?
*
Please Select
SESSION 1 FULL
SESSION 2 FULL
SESSION 3 - July 31 to August 11
Session 4 - August 14 to 25
What type of creativity are you looking to showcase?
*
Please Select
Art
Dance
Music
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Is the camper taking any medications?
*
Yes
No
If yes, please list the medication and any instructions for our staff.
Does the camper have any allergies?
Yes
No
If yes, please describe.
What will be the student's mode of transport to M.A.D. Camp?
*
Overall, how would you rate your mental health?
*
Excellent
Good
Average
Poor
Unsure
Have you felt particularly low, or down for more than two weeks in a row?
*
Very Often
Somewhat Often
Not Very Often
Not at All
During the past four weeks, have you felt depressed, sad, or anxious?
*
Yes
No
Not Sure
During the past four weeks, how often has your mental health affected your ability to do schoolwork or commitments?
*
Very Often
Somewhat Often
Not Very Often
Not at All
How often do you experience the following emotions?
*
Rows
Never
Sometimes
Most of the Time
Always
Calm/Peaceful
Energetic
Gloomy
Angry
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Have you ever been diagnosed with a mental health disorder? If yes, please describe:
*
Have you ever been diagnosed with a mood disorder? If yes, please describe:
*
Is there any other information you would like to share with us?
Submit
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