Lac Ste. Anne County Summer Fun Book Summer Fun 2019 Book | Page 15

Summer Program Registration Form
Community Services Department
FOR OFFICE USE ONLY
DATE: ______________ WAIVER SUBMITTED:
YES
NO EMPLOYEE: ________________________________
PRINT FIRST AND LAST NAME
CONTACT INFORMATION
Parent/Guardian’s First and Last Name: _______________________________________________________________________
Mailing Address: ____________________________________________________________________________________________
City: ______________________ Province: ____________ Postal Code: ____________ Phone: __________________________
Street Address/Rural Address (blue sign): _______________________________________________________________________
Cellular: ______________________ Work Phone: ______________________ Email: ____________________________________
Resident of (check the appropriate box):
Lac Ste. Anne County
Town of Onoway
Village of Alberta Beach
Town of Mayerthorpe
Summer Village (specify): ___________________________
Other (specify): ____________________________________
Emergency Contact (#1), First and Last Name: _________________________________________________________________
Relationship: ___________________________________ Phone: ______________________ Cellular: ______________________
Emergency Contact (#2), First and Last Name: _________________________________________________________________
Relationship: ___________________________________ Phone: ______________________ Cellular: ______________________
PARTICIPANT(S) INFORMATION
FIRST NAME
LAST NAME
DATE OF BIRTH
PROGRAM NAME
PROGRAM FEE
TOTAL $
DAY TRIP INFORMATION (IF APPLICABLE)
Participant’s Name: _____________________________________ Departure/Arrival Location: ___________________________
Medical Information/Allergies: _________________________________________________________________________________
Participant’s Name: _____________________________________ Departure/Arrival Location: ___________________________
Medical Information/Allergies: _________________________________________________________________________________
Incomplete registration forms will not be processed.
T
780.785.3411
TF
1.866.880.5722 www.LSAC.ca
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LSAC SUMMER PROGRAM REGISTRATION FORM & LIABILITY WAIVER