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:
Alabama
Alaska
Alberta
Arkansas
Arizona
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Manitoba
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
Nebraska
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
Nevada
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Québec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Yukon Territory
Postcode/zipcode:
Shirt size:
Adult Medium
Adult Large
Adult Extra Large
Adult Extra Extra Large
Birthdate:
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1995
1996
1997
1998
1999
2000
2001
This is my:
1st camp year
2nd camp year
3rd camp year
4th camp year
5th camp year
6th camp year
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:
01
02
03
04
05
06
07
08
09
10
11
12
/
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Cardholder Name:
Mail to:
22nd Annual International Computer Camps
Box 35018 Sherwood Village RPO
Regina, Saskatchewan, Canada
S4X 4C6
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