Brick Camp - North Langley

Brick Camp - North Langley - July 20-24

We can't wait to see you!
Parent / Guardian Information
Parent / Guardian Full Name

First NameLast Name
Parent / Guardian Email
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child Information
Child full name

First NameLast Name
Preferred name
Birthdate

MonthDayYear
Date
Grade entering in September
Emergency + Medical Information
Emergency Contact Name

First NameLast Name
Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does the child have any allergies?
If yes, please describe the allergies and any reactions
Is an EpiPen required?
Does the child take any medications?
If yes, please list the medications and dosing instructions
Medical conditions, limitations, fears, triggers, or special instructions for staff
Pickup + Consent
Authorized Pickup Person 1 Name

First NameLast Name
Authorized Pickup Person 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pickup Person 2 Name

First NameLast Name
Authorized Pickup Person 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Can your child walk home alone after camp?
Emergency Medical Consent
Media Consent
Refund Policy Acknowledgement
Program Participation Acknowledgement
Parent/Guardian Signature
Date

MonthDayYear
Date
Payment
Camp Registration Payment
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Summer Day Camp Registration
Full payment required at time of registration. No GST.

$280.00CAD

Total

$0.00CAD
Should be Empty:

Brick Camp - North Langley - July 20-24

Parent / Guardian Information

Child Information

Emergency + Medical Information

Pickup + Consent

Payment

Camp Registration Payment*

Camp Registration Payment