2021 Hockey Camp Registration Campers InformationName First Last Sex Male Female Mailing 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 PhoneEmail Date of Birth MM slash DD slash YYYY Health Card #VersionUSA InsuranceParent/Guardian #1 First Last Home PhoneWork PhoneCell PhoneEmail Parent/Guardian #2 First Last Home PhoneWork PhoneCell PhoneEmail If parent or guardian not available, in case of emergency, please contact:Name First Last RelationshipHome PhoneBusiness PhoneCell PhoneI would like to Bunk withHockey InformationPositionLevel BB A AA AA A HL/Select AgeLast Team Played ForPlease specify Jersey Size (adult sizes)* S M L XL Please complete the following the best of your knowledge Medical InformationHas the camper been exposed to any communicable diseases within the 3 weeks prior to camp attendance? Yes No Please provide the date of the last immunization:Diphtheria/Tetanus - Date MM slash DD slash YYYY MMR Measles/Mumps/Rubella - Date MM slash DD slash YYYY Polio - Date MM slash DD slash YYYY HBV Hepatitis B - Date MM slash DD slash YYYY Name of Family Physician First Last PhoneCamper’s present state of health Asthma ADD/ADHD Anxiety Appendicitis Bed-wetting Chicken Pox Diabetes Eating Disorder Epilepsy/fainting Frequent Colds Frequent Ear Infections Hay Fever Head Aches Heart ConditionHepatitis Lactose Intolerant Measles Mumps Nosebleeds Severe stomach aches Rheumatic Fever Sinusitis Sleepwalking Toothache Tonsillitis Whooping Cough Other If "Other", please specifyAllergiesMedicationFoodInsect StingsCarry an Epipen Yes No OtherSpecial medication, dosage and when it should be taken. Please ensure all medication is in the original container. Prescription drugs MUST be in the original pharmacy container.Identify requirements for Special Care while at Camp.List: Medication and Dosage, Treatments, Daily & Weekly Medication Schedule and reason for treatment.Special diet(ie: lactose intolerant, vegetarian, etc.)Camper may participate in Swimming Physical activity OPTIONAL CONTRIBUTION The Ranch is an officially registered Charity. Would you consider supporting our Camper Scholarship fund, Volunteer Summer Staff Scholarship (help for college/university tuition)?Amount ($)(TAX DEDUCTIBLE Registered # 119122273)Other suggestions from parents to assist us to help your child have a successful & enjoyable week(s) of camp.Pre-order a Ranch T-shirt - $20.00 Before May 31, 2021Select SizeAdult SAdult MAdult LAdult XLAdult XXLPre-order a Hat - $22.00 Before May 31, 2021 Yes, I want to Pre-order a Hat Pre-order a Ranch hoodie - $50.00 Before May 31, 2021Select SizeAdult SAdult MAdult LAdult XLAdult XXLWe do not charge for minor medical attention performed by Camp staff. In the case of serious accident or illness, the services of a hospital, physician, dentist or any other related service (i.e., EMS) will be acquired and the charges will be made to the camper’s parents/guardians. Every reasonable attempt will be made to contact parents/guardians prior to services, wherever possible. We will make every effort to ensure that your child does not have a food allergy reaction while at Rocky Ridge. We are not a peanut-free location (although all known peanut products are removed from our kitchen). Our goal is to help your child self-manage his/her condition. Full Registration Fees Residential Camp - $890.00 Hockey Day Camp - $615.00 (Mon. – Fri.) Hockey Camp – “Ice Only” - $360.00 (Mon. – Fri.) Deposit Fees Deposit fees are waived due to COVID 19 Balance due on (or before) camp arrival "Specials" and Extra Fees Register before March 1st and receive a free T-shirt Stay an additional week(s) save 10% off regular camp price Waldo Photos - NEW!) 1 Week Session: $9.99 +$5 for each additional week; Day Camp: $4.99- photos taken thru the week and sent to your mobile phone – more details to come Conditions of Registration By submitting this application, the parent/guardian certifies and agrees that: Medical Information: I certify that this camper is in good health and/or has been seen by a physician prior to attending this present camp week. Rocky Ridge Ranch may, if it considers it necessary, obtain and approve any emergency medical attention which may be reasonably necessary to the applicant camper’s welfare and good health or arrange for any special services or other requirements which it considers to be in the best interests of the applicant camper. The parent or guardian agrees to pay for any and all such services or requirements which have been utilized. Every reasonable attempt will be made to contact parents/guardians prior to services, wherever possible. Liability: While Rocky Ridge Ranch is dedicated to ensuring that every precaution is taken to safeguard the welfare of each applicant camper it is understood that there are certain activities that involve an inherent higher degree of risk. These risks of participation can be significantly reduced by carefully following instructions at all times. I acknowledge, freely accept and fully assume, on my behalf and on behalf of my camper (child), all risks, dangers and hazards of the Camp Activities, whether those risks are inherent or not, including the possibility of personal injury, including death, or property damage and any resulting loss. Rocky Ridge Ranch, its officers, directors, agents and employees (“Releasees”) cannot be held responsible therefore and are hereby released from any and all claims (or future claims) and liability for damages or accidental harm which may occur to the applicant camper or his or her property. Dismissal/Behaviour: Rocky Ridge Ranch’s Camp Director reserves the right to dismiss a camper who in his opinion is a hazard to the safety, rights and well-being of others and who has rejected the reasonable rules and controls of the Ranch. No refund will be issued. I agree to reimburse Rocky Ridge Ranch for any willful or intentional damage to property. Promotional Photos: I give the staff of Rocky Ridge Ranch permission to photograph/video the applicant camper while in attendance at Rocky Ridge Ranch for use in promotional materials which includes but is not limited to website, brochure, postcards, Facebook and other print, digital or electronic media. Lost Items: Rocky Ridge Ranch is not responsible for any personal belongings that are lost, stolen or damaged. Found articles of clothing are collected at the end of each week and held until claimed or at the end of September are donated to a charitable organization. Cancellation Policy: Deposit fees are waived due to COVID 19. Full payment due on or before camper arrival. A deposit fee of $200.00 (Can.) per camper per week is required with the application form. (Day Camp - $100.00 / Hockey Camp - $250.00). The deposit is non-refundable after May 15. Prior to May 15 there is a cancellation fee of $50.00. There is a $25.00 charge for NSF cheques. No refund will be made for late arrival, early departure or dismissal due to disciplinary action. In the case of early withdrawal for medical reasons, refunds will be provided on a prorated basis as determined by the Director. CAPTCHA