Registration

Camper's Information
Camper's Name:

Camper's Email:

Address:

City, State, Zip:

Date of Birth:
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day01020304050607080910111213141516171819202122232425262728293031 Year200820072006200520042003200220012000199919981997199619951994
Age:
---45678910111213141516171819
Gender:
---MaleFemale
Grade Completed (June 2012):
---K123456789101112
Camper Status:
---New to Camp BrainerdI'm a Returning Camper

Parent/Guardian Information
Parent/Guardian (1):

Parent/Guardian Email:

Home Phone:

Work Phone:

Cell Phone / Pager:

Parent/Guardian (2):

Parent/Guardian Email:

Home Phone:

Work Phone:

Cell Phone / Pager:

Emergency Contact (Not Parent/Guardian)
Name:

Relationship to Camper:

Phone 1: (Best to Use)

Phone 2:

Camp Session
---Beginner/Junior - June 19-21 - Gr K-5 - $180Junior High - June 24-29 - Gr 6-8 - $365Jr High Adventure #1 - June 24-29 - Gr 6-8 - $395Music, Art & Drama - June 24-29 - Gr 6-8 - $375Senior High - July 1-6 - Gr 9-12 - $365Junior Week - July 8-13 - Gr 4-6 - $365Sr High Adventure Camp - July 15-20 - Gr 9-12 - $395Mini Camp #1 - July 15-17 - Gr K-3 - $180Mini Camp #2 - July 18-20 - Gr K-3 - $180Jr High Night Owl - July 22-27 - Gr 6-8 - $375Sr High Night Owl - July 22-27 - Gr 9-12 - $375Beginner Week - July 29-Aug 3 - Gr 2-4 - $365Jr High Adventure #2 - Aug 5-10 - Gr 6-8 - $395VBS – Aug 6-10 – Gr K-6 – $25 Suggested Donation
Cabin Mate Request (Only one please.)

T-Shirt Size
---Kid's MediumKid's LargeAdult SmallAdult MediumAdult LargeAdult XLAdult XXL

Church Information
Church membership is not required of campers. However, many churches provide financial support for campers. By providing this information, you will help us generate appropriate billing statements. Thank you!

Camper's Home Church:

Phone:

Address:

City, State, Zip:

Email:

Pastor or Church Officer:

Financial Aid from Church:

Questions or Comments

Registration & Enrollment Agreement (Please Read Carefully)
1. Campers & parents agree to abide by the rules & regulations set forth by Camp Brainerd and the Lehigh Presbytery & follow all rules listed in the Camp Handbook.
2. Camp Brainerd reserves the right to terminate the enrollment of any camper whose physical or mental condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interest of the camp. Tuition is refunded on a pro-rated basis.
3. A $30.00 fee is charged on all Returned Checks or Credit Cards.
4. The campers must be covered by medical and hospitalization insurance provided by the parent or guardian for the duration of the camp season.
5. The camp is NOT responsible for the camper’s personal belongings, while in transit or at camp, if lost, damaged, or otherwise. The camp will make every effort to provide supervision to keep losses at a minimum. (Cell phones, Mp3, Cameras, Video Games, and other electronic devices are NOT allowed at camp or on field trips.)
6. Parents need to ensure that campers have sneakers daily, so that he or she can participate fully in the scheduled activities. This will also prevent injuries.
7. Participation in all activities is essential to your child’s optimum camp experience. Our instructors encourage every child to try and make attempts at all activities. We will make every attempt to communicate with you if lack of participation becomes problematic.
8. All campers MUST be toilet trained.
9. Parent/Guardian’s signature allows the Camp Director, Nurse or staff to apply medical treatment that which does not require medical attention. Signature is consent for transportation in emergency vehicles if deemed necessary. A camper health form must be completed and submitted the during camp sign in on the first day of the campers designated week.
10. Parent/Guardian signature authorizes Camp Brainerd Staff to help apply sunscreen to the camper, if needed.
Adventure Camp Only Parent/Guardian signature gives campers permission to participate and be transported by adults for field trips.

Parent/Guardian gives Camp Brainerd permission to have photographs, video, or audio taken for use in promotional materials and website.
 Yes No

By checking this box I certify that I wish to enroll my child for the week(s) designated above in the 2012 Camp Season and I agree to comply with all terms of enrollment as stated above.

Registration will be complete once a check for the $50 non-refundable registration fee is received. The registration fee is credited toward the total camp fee. In order to receive the Early Bird Discount your camper must be registered and paid in full OR registered with a scholarship application filled out and turned in to the camp office and their family balance paid in full by May 1, 2012. Please make checks payable to:
Camp Brainerd
128 Brainerd Lane
Stroudsburg, PA 18360

A parent or guardian will need to sign a consent form at Registration.

Verify *
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