Weeks *

July 15th - 19th, 2024

August 12th - 16th, 2024

Fees and Discounts

Early bird is only until February 9th

1 week early bird = $410.00 (until Feb 9th)

2 weeks early bird = $785.00(until Feb 9th)

1 week = $425.00

2 weeks = $800.00 ($50 discounted)

Camper Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/ Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Parent / Guardian Name

First Name

Last Name

Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Please list any allergies *

Select all the apply

Drugs/Medications

Food/Dietary Concers

Insect stings/bites

Animals

Seasonal

Other Allergies

Is the camper on any medications? *

Yes

No

Check all that apply *

Fully independent in ambulation

Needs assistance walking

Needs assistance with wheel chair

Requires a gait aid (ie. walker, cane, AFO)

Other

Primary mode(s) of communication *

Verbal

Sign Language

Gestures

Pictures

Symbols

Other

Does your child have a written learning and/or behaviour support plan for home, school or community? *

Yes

No

Which of the Following is the MOST IMPORTANT goal(s) for your child to work on at camp? *

Select all that apply

Cope with life changes

Control anger

Manage worries and fears

Practice social and relationship skills

Improve self-esteem and self confidence

Increase independance

The above information is true to the best of my knowledge and I agree to notify the staff at Fiddlehead Care Farm is there are any cahnges. *

Yes

No