Wait List Registration "*" indicates required fields Camper InformationThe person completing this form is* Parent/Guardian Sponsoring Agency Camper's Name* First Last Birthdate* YYYY dash MM dash DD Age as of July 1st of this year*Please enter a number from 4 to 18.Gender* Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Parent(s) Email*Must be an email you check regularly. Important confirmations and updates will be sent to this address. Attended GLC Before?* Yes No Religious Affiliation (If any)* United Church Anglican Church Roman Catholic None Other Parent(s)/Guardian(s) Name(s)* First Last Parent(s) Phone - Primary Number*Parent(s) Phone - Alternate Number*Emergency Contact*In case the Parent/Guardian is not available NOTE: This cannot be the same as the Parent/Guardian completing this form For Example: Give us the name of an Aunt/Uncle/Grandparent First Last Emergency Contact Phone*Choice of Camp and RatesChoices of Weeks and Dates* Scamper Camp July 3 - 6 Junior 1 July 7 - 13 Junior 2 July 21 - 27 Intermediate 1 July 14 - 20 NOTE: Junior 1 is filling up quickly, please send us an email at firstname.lastname@example.org to inquire if there is still room; or else register your child in Jr 2, where there is still lots of room.Rate you will pay* $260 (Scamper Camp) $525 (Junior and Intermediate) Requesting Geared-to-income or Other Arrangement If this is an additional camper, who is the previous camper? Agency Rate Product Price: Rate Price: $ 0.00 CAD Geared-to-Income or Other Arrangement Golden Lake Camp guarantees that every child who wishes to come to camp will be financially able to do so. Sometimes this involves making special financial arrangements, including arranging subsidies from willing and supportive churches or organizations, or offering special rates or payment plans based on parents’ abilities to pay. If our registrar (or some other qualified person) has already spoken to you about some special arrangement, please choose “Making a special arrangement” from the choices in the following section, and then briefly describe that arrangement in the box below. Your child will then be registered for camp. To request a “Geared-to-Income” rate for your child, please choose the appropriate description from the choices in the following section; then briefly describe your particular situation in the box below, and indicate how we should contact you. Questions? Contact us at 1-888-659-2267 or email@example.com).HiddenGeared 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 firstname.lastname@example.org. Which of the following best describes your family's situation?*We’ve already made a special arrangementWe’re requesting an “Extended-Payment” planWe’re on Works or ODSPWe’re employed but family income is under $25,000 a yearOur income is above $25,000 a year, but under financial stressPlease briefly explain your situation*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 $25 Donation $50 Donation $75 Donation $100 Donation Need a donation 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 as a friend? (Indicate below- *ONE* name only, please.) What is your child’s T-shirt size?*(Every camper will receive a free T- shirt) Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra-Large Other 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 chequeThrough '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: Send your e-Transfer to email@example.com by May 15 unless other arrangements have been made. Include name of Parent, name of Camper, and week of CampNote: Cheque should be payable to Golden Lake Camp. Please note on the cheque the name(s) ofthe child/children you are paying for, and the weeks they will be attending. Mail to: Golden Lake Camp c/o 979 Slate Falls Rd., Denbigh, ON K0K 1L0. Then send an email to firstname.lastname@example.org to say the cheque has been sent.Deposit ($50)* Price: Requesting a receipt for tax purposes?* Yes No 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 Note: A $50 Deposit will be the payment requested at this time.