CAMPER INFORMATION FORM 2010

This form is to be filled in legible print and signed by the parent or guardian,
and returned to your Agency.

Session: 5 Agency: OLQP

Camper’s First Name: Camper’s Last Name: Sex: M F

Birth Date: Grade Completed June 2010: School Attending:

mm / dd / yyyy
Primary Contact Person
First Name: Last Name: *Valid Email required
Home #: Work #: Cell #:
Address:
City: Prov. Postal Code:
Where will you (Primary Contact) be during your child’s stay at camp and include phone numbers?

Are parents [ ] Together [ ] Divorced [ ] Separated [ ] Widowed

Secondary Contact Person
First Name: Last Name: Email:
Home #: Work #: Cell #:
Is the child in Fostercare? [ ] Yes [ ] No What is their status? [ ] PGO [ ] TGO
If yes, please fill out Social Worker’s information below.
Social Worker
Name: Number: Email:

Our Lady Queen of Peace is committed to providing a safe and enjoyable week for your son or daughter. In order to accomplish
this, it is necessary to have as much information as possible about his or her habits, likes and dislikes. Please complete the follow-
ing questions.

What does he or she like to do the most? [ ] Read [ ] Hang Out [ ] Listen to music [ ] Play video games [ ] Dolls [ ] Ride
bike/skateboard [ ] Play Sports [ ] Drama [ ] Sing [ ] Play Instruments [ ] Watch TV

What is your child’s activity level? [ ] Low [ ] Moderate [ ] High

Are his/her friends his/her: [ ] own age [ ] Older [ ] Younger

Is you child in a new situation: [ ] Introverted (Shy) [ ] Extroverted (Outgoing)

How would you describe his/her eating habits: Light? Average? Hearty?

Does he/she have any serious fears? [ ] Water [ ] Spiders [ ] Dark [ ] Homesickness [ ]

MORE TO FILL OUT AND SIGN ON PAGE 2 – TURN OVER

FOR OFFICE USE ONLY
Date: Confirmation:

EXSP: Teepee:

EZC: Dev. Age/Gender BD

 CAMPER INFORMATION FORM CONT.

Are there any special family situations that we should be aware of? (eg. recent divorce, death, or placement in fos-
ter care)

Do you have any advice regarding your camper to aid in their success at the Ranch? (eg. Personal habits, physical
or emotional needs) If you need more space than provided, please attach information on another on another page.

The sun is very strong in the Valley and the Ranch reminds and expects that ALL children put on sunblock
at least 3 times per day, either on their own or with assistance. If they do end up getting a burn they will be
required to wear protective clothing (t-shirts/long pants) for the remainder of the week, no exceptions.
Please ensure that the camper is aware of this expectation.

Can he/she put on their own sunblock and bugspray? Y N

Is there anyone who is court ordered to NOT be contacting or picking up your child at camp? [ ] Y [ ] N
If YES, please provide court ordered documents pertaining to this order.

Our Lady Queen of Peace Ranch (Southern Alberta) Ltd. will be taking pictures throughout the Summer
that may be used in the future for promotional purposes.
Do you permit your child’s picture to be used in this way? [ ] Y [ ] N

If no, do you permit your child to partake in the non-promotional group pictures? [ ] Y [ ] N
ACKNOWLEDGE AND RELEASE
By signing this form, I acknowledge and agree as follows:
1. I have carefully read the Parent Handbook for Our Lady Queen of Peace Ranch Camp. I understand the activities which
are offered at the Camp and the risks involved in those activities. I understand that my child will be taking part in those ac-
tivities unless I have clearly indicated on the Camper Medical Form that my child should not take part in an activity.
2. I understand the facilities and staff assistance which are available at the Ranch and the limitations on what those facilities
and staff can provide. As parent or guardian of the camper, I fully accept all risks which might be entailed by a camping ex-
perience at Our Lady Queen of Peace Ranch (Southern Alberta) Ltd.
3. I certify that the contents of the forms completed for my child are true and complete.
4. I understand that for the purpose of protecting the safety and well-being of campers, the information on this form and on
the Camper Medical Form will be provided to counselors and other Camp staff on a need-to-know basis. This information
will otherwise be kept in confidence, in accordance with the OLQP Privacy Policy, a copy of which is available upon request,
or unless disclosure is otherwise required by law.
5. On my own behalf, and on behalf of my child, I release Our Lady Queen of Peace Ranch (Southern Alberta) Ltd., its offi-
cers, directors, employees and related entities, from all liabilities, claims and causes of action of any nature arising from or
related to any injury suffered by my child while attending Camp or participating in any related activities, including any dam-
age, loss, theft or destruction of property, injury or death, other than those resulting from gross negligence.

PARENT/GUARDIAN SIGNATURE DATE

PRINT NAME:
**FOSTER GUARDIANS ONLY: 1. What is the precise relationship to camper?
2. How long have you known the camper? years months