CAMPER INFORMATION

Name: Birthday: Age at camp: Gender: m Male m Female

Address: City: Postal Code: Home Phone Number:

Session: mAM (9:00am - 12:00pm) - 7-12 years old mPM (1:00pm - 4:00pm) - 13-17 years old Tshirt: Youth mS mM mL or Adult mS mM mL Camp Week: mJuly 7-11, 2014 mJuly 14-18, 2014

PARENT 1/PRIMARY CONTACT

Name: Work Phone:

Home/Cell Phone: Address: (if different than camper)

Email: Does your camper require bussing? mYes mNo

CUSTODY OF CAMPER

Please Specify: m Mother Only m Father Only m Both m Other:

I understand and permit pictures of my child to be taken at camp and used for promotional purposes for the YMCA of Western Ontario mYes mNo

#1 EMERGENCY CONTACT/AUTHORIZED PICK UP *MANDATORY* #2 EMERGENCY CONTACT/AUTHORIZED PICK UP

Name: (other than parent) Home Phone: Name: (other than parent) Home Phone:

Relationship to camper: Work/Cell Phone: Relationship to camper: Work/Cell Phone:

MEDICAL INFORMATION

Does your child have any of the following? m ADD m ADHD m OCD

Please list any medical or dietary conditions we should be aware of:

Please list any medications that your child requires while at camp:

ASSISTANCE / PAYING FOR CAMP

Please list your monthly income (net, after taxes/deductions) _________________. Please send proof of income with your completed registration form.

If you wish to pay for camp please check here m $100/members, $140/non members. Payment can be made in the branch or send a cheque with your registration form. Please make cheques out to YMCA of Western Ontario.

Participants will receive confirmation via phone/email within 2 weeks of registration form being recieved.

I permit my child noted above to attend camp at the YMCA of Western Ontario. I permit my child to participate in the full range of camp activities and authorize the YMCA in the event of an accident or illness affecting the above child to authorize on my behalf all procedures including admission to the hospital and necessary treatment therein, as she/he may deem essential for the care and well-being of said camper. Such action is to be taken only when immediate contact with the undersigned cannot be made.

Signature of Parent/Guardian: Date Signed:

YMCA London Lightning Basketball Camp July 7 - 11, 2014 & July 14-18, 2014

YMCA ofWestern Ontario

ymcawo.ca

LONDON LIGHTNING BASKETBALL CAMP REGISTRATION

mNorthbrae mSt. Anne m St. Pius mSt. Frances

Why Y Day Camp?Experiences that last a lifetime YMCA day camp is the best way to play, build relationships and start to develop a healthy lifestyle like no other day camp in London. For one week only, we are offering London’s first YMCA London Lightning Basketball Camp for campers age 7-17 years old. Get a chance of a lifetime and take part by being on the court, doing drills, workouts and participating with NBA Superstars.

For five thrilling days, you’ll enjoy the excitement of learning basketball skills and being coached by some of your favorite London Lightning players!

Assisting with instruction and motivation will be surprise teammates from the London Lightning who will help you to develop teambuilding and leadership skills.

Commitment to Safety All YMCA day camp sites are accredited by the Ontario Camping Association and are registered with High Five, a quality standard for children’s sports and recreation. We meet or exceed industry standards and continually audit our programs to ensure we’re staying on top of health and safety. Along with having fun and learning new skills, campers will be supervised and supported by caring YMCA staff.

Age Groups: Boys and Girls 7-17 years of age

Session: July 7-11 and July 14-18, 2014

9:00am– 12:00am: 7-12 years of age

1:00pm – 4:00pm: 13-17 years of age

Location: Centre Branch YMCA, 382 Waterloo Street, London, Ontario

Fee: There is no charge for eligible participants. You will be asked for financial information in order to prove eligibility for funding to attend camp.

Registration Options:

Please complete the attached registration form (back cover) by June 13, 2014

Drop Off: Complete and submit form at Centre Branch YMCA - Attn: Alicia Clow-Ennis

Fax: Complete your form and fax it in to us at 519-433-3401

Please call us with any questions, concerns, or help with your registration form: 519-667-3300 or email acennis@ymcawo.ca