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2020 CANADA CAMP
Registration Form
24
Questions
START
Language
English (US)
Japanese
1
Child's Name
*
This field is required.
First Name
Last Name
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Enter
2
My child is...
*
This field is required.
MALE
FEMALE
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Enter
3
Child's Birth Date
*
This field is required.
Date
Year
Month
Day
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Enter
4
Mother's Full Name
*
This field is required.
First Name
Last Name
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Enter
5
Relation to Child
*
This field is required.
MOTHER
FATHER
OTHER
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6
Parent #1 Email
*
This field is required.
example@example.com
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Enter
7
Parent #1 Phone Number
*
This field is required.
Country/ Region Code
Number
Number
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Enter
8
Parent #2 Full Name
Not required, Click "NEXT"
First Name
Last Name
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Next
Submit
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Enter
9
Relation to Child
Not required, Click "NEXT"
MOTHER
FATHER
Other
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Submit
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Enter
10
Parent #2 Email
Not required, Click "NEXT"
example@example.com
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Enter
11
Parent #2 Phone Number
Not required, Click "NEXT"
Country/ Region Code
Number
Number
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Enter
12
Child's Japan Home Address
*
This field is required.
Street Address
Street Address Line 2
City
Prefecture
Postal Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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13
Select ALL MEDICAL ISSUES that apply to your child:
TAKES MEDICATION
HAS ALLERGIES
EXPERIENCES MOTION SICKNESS
OTHER (explain next section)
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14
Please detail ALL MEDICATIONS and ALLERGIES for your child
Type of medications? How many times a day? Specific allergies?
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15
Select all the CHALLENGES your child might have in Canada:
Hearing (ex.: wears a hearing device)
Learning difficulty (ex. ADHD)
Physical Limitation (ex.: walking or running difficulty, wheelchair use)
Seeing (ex.: wears special glasses)
Fears (ex.: heights, insects)
Other (explain next section)
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16
Provide more information about any of the CHALLENGES you selected in the last question
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17
Your Child's PERSONALITY
How HAPPY is your child?
Is your child LAZY?
FRIENDLY?
PATIENT?
ENERGETIC?
Works well in GROUPS?
CONFIDENT?
How HAPPY is your child?
Is your child LAZY?
FRIENDLY?
PATIENT?
ENERGETIC?
Works well in GROUPS?
CONFIDENT?
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18
Select your child's HOBBIES:
SPORTS
READING
SHOPPING
TRAVEL
ENTERTAINMENT
VIDEO GAMES
HIKING/ CAMPING/ OUTDOORS
OTHER
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19
How many times has your child TRAVELLED OVERSEAS?
1
2
3
4
5
More
1
2
3
4
5
More
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20
List the COUNTRIES your child has visited
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21
Select the ACTIVITIES your child participates in, or has participated in, at the OSAKA YMCA:
CAMPS
SPORTS & SPORTS TOURNAMENTS
ENGLISH LESSONS & ACTIVITIES
ROKKO YMCA ACTIVITIES
OTHER
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22
Select all the ENGLISH LANGUAGE TESTS your child has completed:
Eiken
TOEIC
TOEFL
OTHER
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23
Rate your child's English SPEAKING ability
1 Star = Not Good; 5 = Great!
1
2
3
4
5
NOT GOOD
GREAT!
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24
Rate your child's English READING ability
1 Star = Not good; 5 = Great!
1
2
3
4
5
NOT GOOD
GREAT!
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25
Please write any comments you would like the Canada Camp program manager to know about your child
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26
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