Form

Serve-ivor Registration
(Please note: Use the tab button to move through the form. If you scroll down, it can appear that you can't get to the submit button, but if you use the tab button, you will get to the end of the form.)
All registrations must be accompanied by a non-refundable $20 deposit. Deposits can be banked to: Camp Columba Committee, West Pac 03 0915 0252118 00
Which camp are you registering your child for?*

Serve-ivor 1, ages 5-9, 6-9 April 2010 Serve-ivor 2, ages 10-13, 12-16 April 2010
Parent/Caregiver Information
Parent/Caregiver 1
Last Name:*
First Name:*
Home Phone:
Work Phone:
Cell Phone:
Email:
Parent/Caregiver 2
Last Name:
First Name:
Home Phone:
Work Phone:
Cell Phone:
Email:
Mailing Address
Street Address:*
Suburb:
City:*
Postal Code:
Emergency Contacts
Please list 2 alternative emergency contacts should we be unable to reach the listed parents/caregivers.
1. Full Name:*
Relationship(family, friend, neighbour):*
Home phone:*
Work phone:
Cell phone:
2. Full Name:*
Relationship(family, friend, neighbour):*
Home phone:*
Work phone:
Cell phone:
Camper Information
Camper Last Name:*
Camper First Name:*
Date of Birth:*
Month Day Year
Gender*
School:*
Camper's Email
I would like to share a cabin with:
Although we do our best we cannot always guarantee that you will be placed in the same cabin as your friends.
Camp Clothing
We have some really cool camp clothing for sale. You can get your very own camp hoodie or t-shirt. These are black with silver printing.
I would like to buy a Camp Columba T-shirt for an additional $20:

Yes No
If yes, please indicate size:
I would like to buy a Camp Columba Hoodie for an additional $40:

Yes No
If yes, please indicate size:
*T-shirts and hoodies must be prepaid and ordered before the 16th March 2010. Orders may still be placed after this date, but we cannot guarantee they will be ready by the time camp starts.
Camper Medical Conditions and Treatment
Please list any medical conditions and required treatment or medication that we should know about your child:
Dietary Needs
If your child has any special dietary needs can you please take a moment to detail them here for us. We will do our best to meet these needs and may be in contact with you prior to camp.
Parental Declaration
All medical conditions have been declared. I allow Camp Columba staff to give and/or seek appropriate medical help if necessary(including administering paracetemol). In the case of injury or loss I will not hold Camp Columba responsible. I understand Christian principles will be taught at camp. I agree that photos and video footage of my child may be used in future advertising. I agree to future correspondence with my child. I allow my child to go on Camp Columba transport if needed. I understand that I need to sign in and sign out my child from Camp Columba.
I accept these conditions:*

Yes
Collecting my child from camp
Please note that campers can only be collected by their parents/caregivers and the individuals listed below. Even if you plan to pick up your child, your plans may change. Please be sure to list other people here that you may use to transport your child home.
1. Name:*
Home phone:
Cell phone:
2. Name*
Home phone:
Cell phone:
If there is anyone who is not allowed to collect your child from camp, please list them here:
Payment Method
While we require that your registration be accompanied by a $20 deposit, it is also possible to pay the full amount at this time. Please select your payment method and amount below.
Payment Method:*
Payment Amount:*
If you selected other for payment method or amount please give more details here:
Once you have entered all of your information please click the submit button. Thank you.
Should be Empty:

Serve-ivor Registration

Parent/Caregiver Information

Mailing Address

Emergency Contacts

Camper Information

Camp Clothing

Camper Medical Conditions and Treatment

Dietary Needs

Parental Declaration

Collecting my child from camp

Payment Method