EMERGENCY & FIRE SERVICES - JUNIOR FIREFIGHTER ONLINE APPLICATION FORM

CLARINGTON EMERGENCY & FIRE SERVICES

Email Address:*
First Name Of Registrant:*
Last Name Of Registrant:*
Date of Birth:*
Gender:*	M F
Have you ever been to the camp before?:*	Yes No
Mother's Name:*
Father's Name:*
Address:*
Town:*
Postal Code:*
Home Phone No.:*
Work Phone No.:*
School:*
* *Please indicate choice by letter* Week A – July 11 to 15 Week B – July 18 to July 22 Week C – July 25 to July 29 Week D – Aug 1 to Aug 5 Week E – Aug. 8 to Aug. 12
1ST CHOICE:
2ND CHOICE:
3RD CHOICE:
4TH CHOICE:
5TH CHOICE:
Emergency Contact Name:*
Emergency Contact Phone:*
Relationship:*
Family Doctor:*
Doctor phone:*
Health Number:*
Allergies Or Medical Concerns (If any):*
Please list the names of other people that have permission to pick up child at end of program other than guardians:*
Digital Signature of Parent/Guardian: By checking this box, you agree and give permission for your child to take part in the Clarington Junior Fire Fighter Program.*	I Agree

Required fields*