Student Application

First Name: *

Last Name: *

Home Address: *

Postal Code: *

Email Address: *

Home Phone: *

Year of Birth: *

Gender: * Male Female

Have you ever participated in Junior Achievement? * Yes No

Student Health Card Number: *

Do you have allergies or special dietary requirements? * Yes No - If yes, explain:

Do you expect to be taking any prescription drugs during Camp Enterprise? * Yes No - If yes, explain:

Do you have any medical condition of which we should be aware? * Yes No - If yes, explain:

Contact Name: *

Relationship: *

Daytime Phone: *

Ext:

Evening Phone: *

Other Contact Name:

Day Phone:

Night Phone:

To maximize the benefits of Camp Enterprise to all participants we require adherence to the following rules:

1. Students are required to attend throughout the entire Camp Enterprise programme (No Exceptions).
2. No personal vehicles may be brought to the Camp, and visiting by non-participants is prohibited.
3. The possession of alcohol or non-prescription drugs or being under the influence of alcohol or non-prescriptions drugs is not permitted.
4. Participants will be assigned to a specific residence and must not change their residence.
5. No mixing of males and females in the residences is permitted after the curfew.
6. Smoking is not permitted indoors.
7. No cellular phones, pagers or electronic devices are allowed in class.
8. Each night a curfew time will be established, the purpose of which is to ensure students are rested for the next day’s program. You are required to be in your assigned residence by curfew time.
9. Chaperones will be on hand overnight to monitor residences, and you are expected to obey their directions.
10. Failure to conform to these rules will result in immediate expulsion from the Camp with notification to schools and parents.

IF STUDENT IS BELOW THE AGE OF MAJORITY. FOLLOWING CONSENT AND RELEASE MUST BE SIGNED BY PARENT OR GUARDIAN.

IF STUDENT IS ABOVE THE AGE OF MAJORITY, PROVIDE NAME AND PHONE NUMBER OF PERSON TO BE NOTIFIED IN THE EVENT OF AN EMERGENCY.

1. If the above named student becomes ill or suffers an accident while participating in Camp Enterprise, I hereby authorize the members of the Mississauga Rotary Clubs to obtain reasonable and appropriate medical attention in the event that I cannot be reached to give this approval,
2. I authorize the above student to attend Camp Enterprise and I hereby release the Mississauga Rotary Clubs and their members and the University of Toronto and their staff and agents from any claims of any nature in connection with or arising from the student's participation in Camp Enterprise.
3. I have read the Rules of Conduct for Camp Enterprise and if l am selected to attend. I agree to follow these Rules. I understand that if I violate the above Rules, I may be asked to leave Camp Enterprise.