20 CHURCHILL AVENUE KINGSTON 10, TEL. 876-4060879, Email mcintyrej2010@gmail.

com

APPLICATION FORM
A registration fee of _______________________ is required with each applicant.
PLEASE FILL IN THE REQUIRED FIELDS

CAMPERS INFORMATION
MALE

FEMALE

AGE _____ SHIRT SIZE _____________

LAST NAME
RANK

FIRST NAME

MIDDLE

NICK NAME

EMAIL
HOME ADDRESS
TELEPHONE
MAILING ADDRESS

CELL

DATE OF BIRTH
NAME OF SCHOOL/WORK/ORGANIZATION
ADDRESS
TELEPHONE
PARENTS/WARDS INFORMATION

MALE

FEMALE

LAST NAME
HOME ADDRESS
TELEPHONE
MAILING ADDRESS

AGE
FIRST NAME
CELL

MIDDLE NAME
WORK

EMAIL
RELATION TO CAMPER

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20 Churchill Avenue Kingston 10, Tel 876-4060879. mcintyrej2010@gmail.com
Sumac Creations Limited all financial transaction will go through First Global Bank. Account # 8608945

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JEM SUMMER CAMP

20 CHURCHILL AVENUE KINGSTON 10, TEL. 876-406-0879
PARENTS CONSENT FORM
PLEASE FILL OUT THE REQUIRED FIELDS

VENUE:
DATE
DURATION
COORDINATOR

THIS FORM MUST BE FILLED OUT AND SUBMITTED FOR APPROVAL

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TO BE FILL OUT BY PARENT/GUARDIAN

FULL NAME OF CAMPER

FIRST

MIDDLE

LAST

DATE OF BIRTH
DAY

MONTH

YEAR

NAME OF SCHOOL/WORK/ORGANIZATION
ADDRESS
TEL
IN CASE OF EMERGENCY
NAME AND ADDRESS/TEL
APPROVED BY:
PARENTS/GUARDIAN

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GUARDIAN INFORMATION

FIRST NAME

LAST NAME

TEL.
GUARDIANS ADDRESS
EMAIL
PLEASE WRITE BELOW ANY SPECIAL INFORMATION WE SHOULD KNOW ABOUT YOUR CHILD/WARD

PLEASE LIST ANY ACTIVITIES IN WHICH YOU DO NOT WANT YOUR CHILD/WARD TO PARTICIPATE

CAMPER HAS ( ) CAMPER HAS NOT ( ) BEEN IMMUNIZED AGAINST TETANUS WITHIN THE LAST TWO
YEARS.
NAME OF CAMPERS DOCTOR
ADDRESS OF DOCTOR
DOCTORS TELEPHONE

CELL

DETAILS OF ANY INFECTIOUS DISEASE WHICH THE CAMPER HAS BEEN IN CONTACT WITH WITHIN THE
LAST TWO WEEKS.

DETAILS OF MEDICINE/DRUG/TREATMENT WHICH IS BEING TAKEN/FOLLOWED:/BY THE CAMPER:

DETAILS OF ANY KNOWN ALLERGY/SENSITIVITIES (Eg. Penicillin)

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I HAVE READ, AND UNDERSTAND AND AGREE TO THESE CONDITIONS SET FORTH. I CERTIFY THAT THE
ABOVE INFORMATION IS TO THE BEST OF MY KNOWLEDGE TRUE AND ACCURATE.

I
hereby give permission for
to attend the JEM SUMMER CAMP and to take part in the activities and events named. I understand that
in the event of any accident, every effort will be made to contact me, but if this is not possible, I
authorize any of the counsellor to sign on my behalf, any written consent form required by medical
authorities.

SIGNED BY GUARDIAN

DATE

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20 Churchill Avenue Kingston 10, Tel 876-4060879. mcintyrej2010@gmail.com
Sumac Creations Limited all financial transaction will go through First Global Bank. Account # 8608945