SummerCampforChildrenwithFetalAlcoholSpectrum.doc

Summer Camp for Children with Fetal Alcohol Spectrum Disorder 2016 The camp where children with FASD can be themselves! For Who? For children 8 to 17 years of age with Fetal Alcohol Spectrum Disorder. When? (Please check which camp your child would like to attend) Camps run MONDAY 1pm to FRIDAY 1pm. □ Camp 1: July 4-8, 2016 Girls Ages 7 - 10 □ Camp 2: July 11-15, 2016 Girls Ages 11 - 13 □ Camp 3: July 18-22, 2016 Boys Ages 7 - 10 □ Camp 4: July 25-29, 2016 Boys Ages 11 - 13 □ Camp 5: August 8-12, 2016 Girls Ages 14 – 17 Camp 6: August 15-19, 2016 Boys Ages 14 – 17 Where? French Bay Provincial Park-63218-RGR 411 #1, Cold Lake, AB How Much? $500.00 per child Registration Deadline Full payment or confirmed payment arrangement must be accompanied with completed application forms. If funding is an issue, please contact the Lakeland Centre for FASD for assistance. Return Camp Packages to: LCFASD Box 479 Cold Lake, AB T9M 1P1 Fax: 780-594-9907 E-mail: admin@Lakeland FASD Summer Camp Camp Registration - 2016 Camper’s Information Name: Mailing Address: City: Postal Code: Phone: Male □ Female □ Birthday: Medical Conditions: Emergency Information: Primary Contact: Name: Relationship to camper: Home Phone: Alternate Phone: Will you be away from these numbers during the campers stay: Yes No Where will we be able to contact you in case of an emergency: ______________________________________________________________________________ Alternate Contact: Name: Relationship to camper: Home Phone: Alternate Phone: Address: Personal physician: Office Address: Telephone: (Bus.) (Cell/Pager) Alberta Health Care Number: Social Worker (if applicable): Telephone: (Bus.) (Cell/Pager) Specific Information: Child’s Diagnosis: What are your child’s secondary disabilities? (Please check all that apply) Sensory issues Fine Motor Difficulties Visual Perceptual Motor Depression Anxiety ADHD AD