Registration Camper InformationThe person completing this form is* Parent/Guardian Sponsoring Agency Name* First Last Birthdate* MM slash DD slash YYYY Age*Please enter a number from 6 to 18.Gender* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Attended GLC Before?* Yes No Religious Affiliation* United Church Anglican Church Roman Catholic None Parent(s)/Guardian(s) Name(s)* First Last Parent(s) Email*Must be an email you check regularly. Important confirmations and updates will be sent to this address. Parent(s) Phone - Primary Number*Parent(s) Phone - Alternate Number*Emergency Contact* First Last Emergency Contact Phone*Choice of Camp and RatesChoices of Weeks and Dates* Junior 1 July 3 - 9 Junior 2 July 10 - 16 Intermediate 1 July 17-23 Rate you will pay* $420 (1st camper - one week) $360 (Additional camper, or an additional week for 1st camper) Requesting Geared-to-income (further down on form) Other amount (as arranged with registrar) If this is an additional camper, who is the previous camper? Agency Rate Product Price: RatePlus Deposit Price: $ 0.00 CAD Geared to IncomeOur "Geared-to-Income" and "Extended-Payment" Plans guarantee that no child who wishes to attend Golden Lake Camp is ever turned down for financial reasons. Simply complete the section below and send in the form. Our registrar will then register your child for camp, and contact you by phone or email, to work out with you a rate you can afford, or design an "Extended-Payment plan that will work for you. If you have questions, call us at 1-888-659-2267, or email us at email@example.com. Which of the following best describes your family's situation?*We are on Ontario Works or ODSPEmployed but family's income under $25,00 a yearIncome above $25,000/year, but under financial stressPlease briefly explain your situation*How should we contact you?* By phone By email Either is fine PLEASE NOTE: When we contact you, all information we receive is confidential.Like to donate to our Camper Subsidy Fund?*Our Camper Subsidy Fund is used to help children who would otherwise be unable to attend camp for financial reasons. A tax receipt is available for all such donations. Yes, I would like to donate Sorry, not this year Donation Amount $10 $25 $50 $75 $100 Need a receipt for tax purposes?* Yes No Other Helpful InformationDoes this camper have any serious allergies / medical conditions / mental health issues / behavioural issues (A detailed health form will be sent to you later)*No issuesSerious allergiesOther serious medical issuesBehavioural issuesMental health issuesPlease contact us for detailsDetails you would like us to know Also inviting a friend?* No Yes Like to be in the same cabin/tent as a friend? (Indicate below--one name only, please.) About Vaccination, is this camper Fully vaccinated Partially vaccinated Unvaccinated Would rather not disclose (We're asking in the unlikely case of an outbreak, when we would need to report to the area's Medical Officer of Health, who might request this information)How many different ways did you hear about Golden Lake camp? Please check all that apply* Family/ friends/ my child's friends Ottawacamps.com website Ottawacamps.ca website My child's school Social media (Facebook, Twitter, Instagram, etc,) On the radio Our camp's website (www.goldenlakecamp.ca) Google search Our local church Other Other Paying for your child's attendanceHow do you plan to pay*Please make a selectionCredit CardE-transferPersonal chequeOther arrangementThrough 'Geared-to-income'Note: You will be directed to PayPal to submit the payment using your credit card (a PayPal account is not needed)Note: You have selected Payment by "Other Arrangement". We will contact you to finalize details.Note: You have selected Payment by "Geared-to-income". We will contact you to finalize details.Note: Send your e-transfer to firstname.lastname@example.org. Please include the camper's name and week of the camp Security Question: Please enter "Deacon" as the answer to your security question, and you can use "Where is the camp?" as your question.Note: Cheque should be payable to Golden Lake Camp. Mail to: Mary Wales, Golden Lake Camp Registrar 94 Ungar Island Rd., Desoronto, ON K0K 1X0Do you plan to submit the full amount, or a $50 deposit?About refunds: A full refund, minus a $50 administration fee, is available up to two weeks before the child's planned arrival time at camp, or up to the day of arrival, in the event of a confirmed medical or family emergency.I will submit the full amountI will submit a $50 depositI am applying under "Geared-to-income"Deposit ($50)* Price: Sponsoring Agency InformationName of Agency to be Billed* Agency Contact Name* Agency Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Agency Contact Email* Agency Contact Phone*Prove you're a human...Please enter the text you see below into the box, to prove you're a human.Total $ 0.00 CAD Note: A $50 Deposit will be the payment requested at this time.