1. Application Form Please fill out this form and return it by mail, e-mail or fax. Camp Five Cell : 1 403.483.5905 Anne McMechan camp5@jemdunham.com 1. Participant Information Last nameGender Complete Postal address Date of birth PhoneE-mail 2. Parent Information (father, mother or guardian) Complete name Home phone Office phone Third party contact for emergency Phone ( ) Would you be interested in receiving occasional news from Camp Five? yesno MF Commitment: One condition for being accepted to this week-end is that your children will participate in all activities planned. It is really important that they accept the rules that are made and they respect others. Pocket money: Your children will not need extra money. This year our camp will be held at the base of Youth with a Mission Dunham, which is located 60 minutes from Montreal. The camp will begin Friday, November 16 at 6:30pm and will last until Sunday, November 18 at 2:00 pm. Parents are invited to bring a lunch and join us for a picnic with their children at 12:30pm. The price of this camp is $60 (for 2 children there will be a special price). Cheques should be payable to Youth With A Mission. Registration before 12 November 2012. We will hold our missionary outreach activities on Saturday and Sunday in Cowansville and Dunham. There we will meet with people to share God’s love in words and actions. Address: YWAM Dunham – 165, rue de collège, Dunham, QC Directions: Highway 10, turn off on exit 68 for QC-139 toward Cowansville/Sutton/Boulevard David-Bouchard/Granby. Turn left onto QC-139 S. Turn R onto Rue du S/QC 202 O (signs for Dunham). Continue on QC 202 O. Turn left onto Chemin du Collège. The base in on the left. Adresse complète Cell phone ( ) First name

2. 4. Health and Insurance Health Insurance number (mandatory) yes If necessary, can Tylenol be administered to your child? no Does your child suffer from any allergies? Explain. Please check the following elements that apply to your child. Attention deficit Hyperactivity Convulsion/seizures Diabetes Ear infection Asthma Lactose intolerant Bed wetting Nose bleeding Recent major injuries Sleepwalking Please attach a note with additional information that would be useful related to the boxes checked. THIS APPLICATION WILL NOT BE CONSIDERED WITHOUT THE SIGNATURE OF THE CHILD AND THE PARENT. I have read and understand both pages of this application form. Child’s signature Parent’s signature Date Other Name of the regular doctor Phone number Does your child currently take any other medications? If yes, what and in what dosage? During Youth With A Mission activities we commit to ensure the maximum safety (security) of every participant. In spite of all our efforts, an accident may occur. A person qualified in first aid is part of the team. We inform you that if necessary your child will be transported to the nearest emergency room from our place of activity and you will be informed about same immediately. Discharge: To my knowledge, there is no reason, other than the information indicated on the form, which would prevent my child to participate in this camp, except those noted by the doctor and I authorize a doctor or other emergency personnel to intervene if needed. I have brought to your attention any information about my child that is necessary for the proper functioning of the group during this camp. I allow my child to be part of the outreach activities outside of the YWAM Base on Saturday and Sunday (November 17&18 2012). Please explain the columns that were marked. Note any information which could be useful for the people in charge of the health of the children. If you have marked one of the columns above, is your child presently being treated? If yes, what treatment is he/she receiving? Dosage?