Application for 19th 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 2010-1
Full!		 July 5 - July 9 Age 12 - 17 (inclusive)
On or before May 17: CA$225
after May 17: CA$250

  
Camp 2010-2
July 12 - July 16 Age 12 - 17 (inclusive)
On or before May 17: CA$225
after May 17: CA$250

  
 
Personal Data
Name: Gender: F   M   
Mailing address: Home phone:   
City: Province/state:   
Postcode/zipcode: Shirt size:    
Birthdate: This is my:    
Provincial health  card number: (or health insurance plan and number)   
Camper's email: (if camper has one; otherwise, parent's email)  
 
 
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/Amex (billed by Metric Hosting Ltd.)

Card#:   Expiry: / Cardholder Name:

Mail to:
19th Annual International Computer Camps
Box 35018 Sherwood Village RPO
Regina, Saskatchewan, Canada
S4X 4C6
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