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Go Wild @ MTA
Registration

Online Registration

Schedule

Application Information:

1. Applicants should apply either online, by fax or email. Online registration is preferred and available at http://www.mta.ca/summer Alternatively, fax or mail the form (see following page).
2. The total fee for the camp is $100. A $50 deposit is required to secure your place. Please refer to PAYMENT INFORMATION (see following page).
3. Upon receipt of the application and deposit, a letter or email will be sent to confirm your application status.
4. Please keep a record of the payment for reference.
5. The remaining fee should be paid no later than one week before the camp starts.

1. Upon receipt of the application and deposit, a letter or email will be sent to confirm your application status. 2. Please keep a record of the payment for reference. 3. The remaining fee should be paid no later than one week before the camp starts.
	PAYMENT INFORMATION ** Please ensure that the student’s name is clearly indicated on the payment. a) Cheque or bank draft: payable to Mount Allison University and mailed to:
		Go Wild @ MTA / Summer program Conference Services Mount Allison University 155 Main Street, Sackville, NB, E4L 1B5
	b) Credit Card: Visa or Mastercard - contact the summer program office at (506) 364-2253 to arrange your payment

Note:
• In the event that a student needs to withdraw prior to the start of camp, the fees will be returned (less the $40 non-refundable deposit) provided the request is received in writing a week before the camp start date. For cancellation after the start date, no refund is available.
• Camps are conditional upon enrollment. A full refund is issued in the event a camp is cancelled. Mount Allison University reserves all rights to cancel or change the content of the camp as advertised should unavoidable circumstances arise.

Go Wild Registration

Family Name:		Given Name:
Gender:	Female Male
Date of Birth:
Current School: (optional)		Current Grade:
First Language:

Address:

Address:
City:		Province/State:
Postal/Zip Code:
Telephone:		Fax Number:
E-mail:

Parent/Guardian:

Name:		Relationship:
Address (if different from above)
City:		Province/State:
Postal/Zip code:
Home Phone:		Business Phone:
Cell Phone:		Fax Number:
E-mail:

Medical Information:

1. Does your child have any of the following medical conditions which will require special care?
Severe Asthma Seizure/epilepsy Diabetes Other - please specify:

2. Is he/she on any medication? If yes, please specify:


3. Does your child have any life threatening or non-life threatening allergies? If yes, please specify:


4. Please indicate any additional health issues that the group leaders should be aware of.


5. Please indicate any special food requirements.


How did you hear about our programs?


Authorization:

I acknowledge all information given is accurate to the best of my knowledge. In permitting my child to attend Mount Allison University summer program, I, the undersigned, permit my child to participate in the full range of activities and authorize the Program Coordinator or his/her appointed, in the event of accident or illness affecting this above named student, to authorize on my behalf all procedures, including admission to hospital and necessary treatment therein, as he or she may deem necessary for the care and well-being of the student. I understand that my child is obliged to abide by the rules and regulations of Mount Allison University and failure to do so may result in suspension from the program without any refund.

Name of parent/guardian (as a sign of agreement):
Date:

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