Northwestern Ontario Innovation Centre BizKids Camp 2018 Registration Form PARENT / GUARDIAN INFORMATION (If different, include mailing address for receipt) Mrs. Ms. Mr. Name: Address: City: Province: Postal: Phone: Work Phone: May we contact you via email: Yes No How did you hear about this camp: CAMPER INFORMATION (attach additional medical information if needed) Name: Birth date: Age: Gender: Female Male Grade Entering (Fall 2018): Camper photo for promotion? Yes No Family Doctor Doctor’s Phone #: Health Card#: Medication: Special Needs/Allergies: Emergency Contact Name: Emergency Contact Phone Number: T-Shirt Size (please circle both type and size): Youth / Adult Small / Medium / Large / X-Large Registration Information: (Please number your top choice) BizKids Camp July 16th July 20th – BizKids Camp August 20th 24th –August If attending with a friend, include their name: Friends Phone #: Gender: F M Disclaimer & Payment Information I, the undersigned, the Parent/Guardian of the above-mentioned camper, do hereby consent to his/her participation in the Northwestern Ontario Innovation Centre BizKids Entrepreneurship Camp 2018 program and related activities. I understand that BizKids is a program designed to encourage entrepreneurship, creativity and leadership development and will involve some hands-on activities and field trips. I consent to and assume all risks and hazards of, and incidental to, the participation of the above-mentioned camper in the activities of BizKids Camp. Fee: ___ $175.00 (including tax) per child Name: Cheque Visa Mastercard Signature: Expiry Date: Date: Credit Card #: Please make cheques payable to the: Northwestern Ontario Innovation Centre Submit Form: By email to -or- in person to the Northwestern Ontario Innovation Centre, 34 Cumberland St. N., Suite 603, 807-768-6682 Office Use Only Database Authorization # Date Processed Invoice Number
Northwestern Ontario Innovation Centre BizKids Camp 2018 Registration Form PARENT / GUARDIAN INFORMATION (If different, include mailing address for receipt) Mrs. Ms. Mr. Name: Address: City: Province: Postal: Phone: Work Phone: May we contact you via email: Yes No How did you hear about this camp: CAMPER INFORMATION (attach additional medical information if needed) Name: Birth date: Age: Gender: Female Male Grade Entering (Fall 2018): Camper photo for promotion? Yes No Family Doctor Doctor’s Phone #: Health Card#: Medication: Special Needs/Allergies: Emergency Contact Name: Emergency Contact Phone Number: T-Shirt Size (please circle both type and size): Youth / Adult Small / Medium / Large / X-Large Registration Information: (Please number your top choice) BizKids Camp July 16th – July 20th BizKids Camp August 20th –August 24th If attending with a friend, include their name: Friends Phone #: Gender: F M Disclaimer & Payment Information I, the undersigned, the Parent/Guardian of the above-mentioned camper, do hereby consent to his/her participation in the Northwestern Ontario Innovation Centre BizKids Entrepreneurship Camp 2018 program and related activities. I understand that BizKids is a program designed to encourage entrepreneurship, creativity and leadership development and will involve some hands-on activities and field trips. I consent to and assume all risks and hazards of, and incidental to, the participation of the above-mentioned camper in the activities of BizKids Camp. Fee: ___ $175.00 (including tax) per child Name: Cheque Visa Mastercard Signature: Expiry Date: Date: Credit Card #: Please make cheques payable to the: Northwestern Ontario Innovation Centre Submit Form: By email to -or- in person to the Northwestern Ontario Innovation Centre, 34 Cumberland St. N., Suite 603, 807-768-6682 Office Use Only Database Authorization # Date Processed Invoice Number
bizkidsregistrationform2018.docx