Lac Ste. Anne County Summer Fun 2017 Book Summer Fun 2018 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 Page 1 of 2 LSAC SUMMER PROGRAM REGISTRATION FORM & LIABILITY WAIVER