Untitled - BCM Ireland

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Untitled - BCM Ireland
Castledaly Manor
We ask that Parents fill out this form:
!
Camp (please tick )
!
Refocus (5th & 6th Yr students)
◻️
◻️
27th Jul – 2nd Aug
Junior (Ages: 8-11)
________________________________________
Forename: __________________________________
Class_______________
Surname: ___________________________________
◻️
3rd-8th Aug
Campers Information
Forename:______________________________
Surname:_______________________________
D.O.B: ____________________
Age at camp: ______________
Home Address:
________________________________________
________________________________________
________________________________________
________________________________________
Home Phone: ___________________________
!
Address if different: _________________________
Friends whom you wish to share with?
____________________________________________
________________________________________
Home Phone: _______________________________
________________________________________
Mobile Phone: ______________________________
!
◻️
13th-19th July
Senior (Ages: 11-14)
Parents Information
!
28th Feb - 2nd Mar (See website for details)
Youth (Ages: 15-17)
School: _________________________________
Email Address in block capitals:
Does the camper have any of the following
__________________________________________
we should be aware of?
Can camp information letter be sent by email?
• Medical Conditions: Yes___ No___
Yes ◻ ️
If yes, please state:
Consent
________________________________________
________________________________________
• Dietary Requirements: Yes ___ No ___
If yes, please state:
________________________________________
________________________________________
Emergency Contact: _____________________
Phone Number: _________________________
Family Doctor’s Name: ___________________
Doctors Number: ________________________
Date of Last Tetnus Injection: _____________
!
No ◻ ️
Please tick to accept:
• I, the Parent/Guardian hereby give my consent for
the above named to attend BCM residential Camp. ◻
• I consent to the above named to participate in all
on-site and off-site activities all under proper
◻
supervision
• I also consent to the above name being included in
photographs of the activities.
◻
In order that the camp be enjoyable for all, certain
rules must apply and I accept that the above
named must abide by these rules.
Signed: Parent/ Guardian
_________________________________________
I enclose: € __________
Cheques or Postal orders to be made out to
BCM
Return to:
BCM Camps
[email protected]
Castledaly Manor,
Phone: 090 648 2222
Moate
www.bcmireland.ie
Athlone
Co Westmeath.