Application Form - Annual International Computer Camps

Application for 22nd Annual International Computer Camps being held at the University of Regina, Regina, Saskatchewan, Canada
	Please check the FAQ for how to apply and fee schedule. Then complete, print, and mail this application form.

Choice of Camp(s)

	Camp 2013-1	July 8 - July 12	Age 12 - 17 (inclusive)	On or before May 15: CA$250 May 16 - June 22: CA$275 After June 22: CA$300
	Camp 2013-2	July 15 - July 19	Age 12 - 17 (inclusive)	On or before May 15: CA$250 May 16 - June 22: CA$275 After June 22: CA$300

Personal Data

Name:		Gender:	F M
Mailing address:		Home phone:
City:		Province/state:
Postcode/zipcode:		Shirt size:
Birthdate:		This is my:
Provincial health card number:	(or health insurance plan and number)
Camper's email:	(if camper has one; otherwise, parent's email)
Indicate any medical condition, allergy or limitation of which camp staff should be aware:

Parent/Guardian Contact Information

Mother's name:		Mother's day phone:
Father's name:		Father's day phone:

Liability Waiver

	The undersigned hereby releases and holds harmless Mentor Systems Inc., Metric Hosting Ltd., and University of Regina, its officers, employees, representatives, agents, successors, and assigns, from all liability for any injury or damage to person or property howsoever caused, resulting from the attendance of the aforementioned registrant in the camp. This waiver must be signed by a guardian of the minor before participation in the above registered camp can be permitted.
	Guardian Name: Signature:___________________________________

Payment

Please make cheque/money order payable to Mentor Systems Inc.
or pay by Visa/Mastercard

Card#: Expiry: / Cardholder Name:

Mail to:
22nd Annual International Computer Camps
Box 35018 Sherwood Village RPO
Regina, Saskatchewan, Canada
S4X 4C6

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