For Early Bird rate return completed signed enrollment with payment in full by Early Bird deadline to receive the printed rates.

Check box for selected session:

	Two Week A	2 July - 15 July		Three Week A	2 July - 22 July
	Two Week B	16 July - 29 July		Three Week B	23 July - 12 August
	Two Week C	30 July - 12 August		Four Week	16 July - 12 August
	Two Week D	13 August - 26 August		Six Week	2 July - 12 August
	Other	Pre-arranged with Directors		Seven Week	CIT/JC (By Separate Application)

Camper's First Name: M/I: Last Name:

Age as of 1 July 2017:	Birthdate (DD/MM/YR):	Camper's Grade (May 2016):	Nickname:

Name of Parents or Guardians

Camper lives with:   Mother and Father Mother Father Stepmother Stepfather Grandparent Other

Home Street Address

City Prov./State P.C./Zip

Home Phone Work Phone Fax

Include international dialing code

Cell Phones E-mails

Summer Cottage Phone Camper's email

Emergency Contact (other than parent) Relationship Phone

Name of Family Physician Phone

School Phone

Camp Chikopi 2017 Registration

Parents Names Camper's Name

Select a Session		15% Mega Early Bird Ends 30 November 2016	10% Super Early Bird Ends 31 December 2016	5% Early Bird Ends 31 January 2017	Regular Fee 1 February onwards
	Two Week A Avail. Paintball (12-17 yrs old)	$1530	$1620	$1710	$1800
	Two Week B	$1530	$1620	$1710	$1800
	Two Week C Includes Canoe Trip	$1530	$1620	$1710	$1800
	Two Week D	$1445	$1530	$1615	$1700
	Three Week A Avail. Paintball (12-17 yrs old)	$2231	$2362	$2494	$2625
	Three Week B Includes Canoe Trip	$2231	$2362	$2494	$2625
	Four Week Includes Canoe Trip	$2890	$3060	$3230	$3400
	Six Week Includes Canoe Trip. Avail. Paintball (12-17 yrs old)	$4207	$4455	$4702	$4950
	Six Week Sons of Military & Veterans. Proof of Service Required	NA	NA	NA	$3000
	Seven Weeks CIT/JC By Separate Application

Add			Add
	Chaperone TO Camp Chikopi Sunday's	$175.00		Niagara Falls Day Trip 19th July 2017	$175.00
	Chaperone TO Toronto Saturday's	$175.00		North Bay Triathlon 3 July	$150.00
	Full Rental - Bedding, towels, trunk, lifejacket	$90.00		North Bay Regatta 8 July Date to be Confirmed	TBD
	Rental - Bedding and towels	$50.00		North Bay Regatta 15 July Date to be Confirmed	TBD
	Rental - Trunk	$20.00		Paintball - 5 July (11-4pm) Paintball - 11 July (11-4pm)	$60.00 $60.00
	Rental - Lifejacket	$20.00		Tuck shop - unused tuck is refunded	$100.00
	Donation: Chikopi Charitable Foundation	$25/$50/$100 - Other		Tuck shop - unused tuck is refunded	$150.00
	Other			Tuck shop - unused tuck is refunded	Other

For more on rates and dates, please visit: www.campchikopi.com

Parents Names Camper's Name

Camp Chikopi Registration Terms and Conditions, 2017

1. Early Bird Registrations must be received with full payment and completed signed registration form no later than due date indicated.
2. $500 non-refundable deposit required with every registration, deposit is applied to the invoice.
3. In the event of withdrawal or cancellation, 50% of tuition balance is refundable until April 1 2017. Tuition is non-refundable after April 1st, when operating expenses are fixed for the summer. No credit is given for late arrival or early withdrawal.
4. Parents/Guardians agree to make tuition payments promptly. Late payments are subject to a service fee of $100 per month.
5. A Camper's place cannot be held if balance of payment is not received by April 1, 2017. Priority will then be given to the Wait List.
6. Camper may change or extend their session, subject to availability and a service fee of $100.  A revised tuition bill will be provided.
7. Base tuition fees do not include 13% HST tax, Tuck fees or optional extras.
8. Camp offers limited bus airport transport services. Detailed Transport information can be found in our Travel Information Form.
9. Camp is not responsible for lost or stolen property. Avoid sending expensive items and please label all belongings.
10. Registration Credit - Families registering more than one sibling at Camp Chikopi will receive $100 credit for each additional sibling enrolled. Credit will be applied to the final expense statement at summer's end. Early Bird Registrations excluded.
    
11. Referral Credit - Families referring a new family that registers a Camper will receive a $100 credit per Camper. Credits will be applied to the final expense statement at summer's end.  Early Bird Registrations excluded.
    
12. Camp Chikopi assigns campers to cabins based on their age as of July 1 of the summer sessions.
    
13. Camp Chikopi maintains a Code of Conduct for campers, and reserves the right to assess a Camper's behavior, to revise a Camper's stay, or to dismiss a Camper early, when it is deemed necessary in the best interest of the child and Camp Chikopi. No refunds shall be given in these cases. Parents agree to provide full information on Campers in advance.
    
14. Parent Permission is given herewith to use photos/video of your child for Camp archival records or promotional purposes.

I desire my child to participate in the full camp program and all activities including paintball and canoe tripping, unless I advise the Camp as to any restriction in writing. In consideration of the acceptance of my child into the camp program, I hereby release Camp Chikopi, its officers, Directors, volunteers and employees, from all claims arising from my child's participation in camp activities. I authorize the camp to secure medical treatment for my child when appropriate. If for any reason my child requires medical attention beyond that furnished by the camp, I agree to be responsible for any expenses incurred. I acknowledge that the camp activities and any medical treatment will be performed in the Province of Ontario, and that the Courts of Ontario shall have exclusive jurisdiction over any claims, legal dispute or cause of action arising out of my child's stay at Camp Chikopi. I hereby agree that if I commence any legal proceedings, they will be held only in the Province of Ontario, and I hereby irrevocably submit to the exclusive jurisdiction of the Courts of Ontario.

I have read, understood, sought legal advice if necessary and agree to all of the above terms and conditions of registration and payment of the total camp bill to be applied to the above camper's account. I understand that my signature below and payment enclosed are required to confirm my son's enrollment.

Parent/Guardian Signature:

Date (DD/MM/YY)

Tuition Worksheet ($500 Deposit required with every enrollment)

Choose your fee from the Enrollment Fees Chart:
Add 13% of the base fee for tax (HST):
Add Tuck Account Deposit ($50, $100, $150 or Other):
Add optional extras:
TOTAL CAMP BILL:

An enrollment confirmation / tuition statement will be issued to you on receipt of your son's enrollment.

Please make US or Cnd. checks payable to Camp Chikopi. Remit to: Camp Chikopi, 2132 NE 17 Terrace, Fort Lauderdale, FL 33305 or complete the following Credit Card authorization information. Camp Chikopi accepts VISA and MasterCard

Card Number Expiry Date C.V.V

Name of Cardholder Signature of Cardholder

Parents Names Camper's Name

Please share any comments, instructions, reminders, cabin requests, or questions.

Health Snapshot: does your son have any allergies, asthma, ADHD, toileting, sleep, emotional, anxiety or other challenges?

Please list your son's brothers and sisters, with name and age.

What are your son's favorite activities at Camp Chikopi?

My son has attended Camp Chikopi for summers      OR...      My son is new to Camp Chikopi

May we use your name as a reference for prospective Camp Chikopi families?      YESNO

Please complete for our Alumni Records.

How did you learn of Camp Chikopi?

List family members who attended Camp Chikopi/Akomak What years?

Referrals: is there a family to whom you would like us to send Camp Chikopi information?

Boy's Name Age School

Parents' Names Email

Street Address Phone

City Prov./State PC/ZIP

For complete parent information, visit the Camp Chikopi web page: www.campchikopi.com

Further information and Camper forms will be emailed to you in Spring 2017