Registration

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Primary Contact Info - Step 1 of 8

Parent/Guardian Info

Name of person registering camper(s) *

First

Last

Your Email *

Relation to camper(s) *

Parent
Legal Guardian
Grandparent
Other

Name of Parent/Guardian #1 *

First

Last

Email of Parent/Guardian #1 *

Adress of Parent/Guardian #1 *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Numbers of Parent/Guardian #1 (enter up to 3) *

Please enter phone numbers we can use to contact you during camp, if needed.

Phone Number

Name of Parent/Guardian #2 *

First

Last

Email of Parent/Guardian #2 *

Address of Parent/Guardian #2 (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Phone Numbers of Parent/Guardian #2 (enter up to 3) *

Please enter phone numbers we can use to contact this person during camp, if needed.

Phone Number

Emergency Contact Info

Emergency Contact Full Name *

First

Last

Emergency Contact Phone Number *

Secondary Emergency Contact Full Name

First

Last

Secondary Emergency Contact Phone Number

Pediatrician's Info/Camp Agreement

Pediatrician's Name *

First

Last

Pediatrician's Phone Number *

Pediatrician's After-Hours Phone Number

CCC Camp Agreement

I recognize that camp involves outdoor activities and that an injury to my child may be sustained. The child(ren) listed on this form has/have my permission to attend the CCC Camp indicated by this registration. In the event that medical treatment is necessary, every effort will be made to contact me. If I cannot be reached, I give permission to camp staff to secure the services of a licensed physician to provide the care necessary for my child's well-being and agree to pay the charges for such. The camp cost will be refunded if cancellation is received one month prior to the start of camp. There will be no refunds beyond this date except in the event of illness. In the event of illness, notice must be received no later than the first day of camp at 9:00am.

Acknowledge *

I agree with these terms

Camper Info 1

Camper's Name *

First

Last

Camper's Gender *

Male
Female

Parents'/Guardians' Full Names

Age (as of camp) *

Birthday *

Grade Entering this Fall (if applicable) *

T-shirt Size *

Group/Cabin Buddy Request

Preo Overnight: If registering for Camp Preo and entering grade 1 or 2, will your camper attend our special overnight camp experience on the Wednesday night of camp?

This child may receive the following medications if needed:

Tylenol
Ibuprofin
Benadryl
Dramamine

Does this child get carsick? *

Special Medical or Dietary Needs

Permission to Use Likeness: As a parent/guardian, I give CCC permission to use image(s) of this child in future advertising (brochures, website, etc.) *

Camper Info 2

Camper's Name *

First

Last

Camper's Gender *

Male
Female

Parents'/Guardians' Full Names

Age (as of camp) *

Birthday *

Grade Entering this Fall (if applicable) *

T-shirt Size *

Group/Cabin Buddy Request

Preo Overnight: If registering for Camp Preo and entering grade 1 or 2, will your camper attend our special overnight camp experience on the Wednesday night of camp?

This child may receive the following medications if needed:

Tylenol
Ibuprofin
Benadryl
Dramamine

Does this child get carsick? *

Special Medical or Dietary Needs

Permission to Use Likeness: As a parent/guardian, I give CCC permission to use image(s) of this child in future advertising (brochures, website, etc.) *

Camper Info 3

Camper's Name *

First

Last

Camper's Gender *

Male
Female

Parents'/Guardians' Full Names

Age (as of camp) *

Birthday *

Grade Entering this Fall (if applicable) *

T-shirt Size *

Group/Cabin Buddy Request

Preo Overnight: If registering for Camp Preo and entering grade 1 or 2, will your camper attend our special overnight camp experience on the Wednesday night of camp?

This child may receive the following medications if needed:

Tylenol
Ibuprofin
Benadryl
Dramamine

Does this child get carsick? *

Special Medical or Dietary Needs

Permission to Use Likeness: As a parent/guardian, I give CCC permission to use image(s) of this child in future advertising (brochures, website, etc.) *

Camper Info 4

Camper's Name *

First

Last

Camper's Gender *

Male
Female

Parents'/Guardians' Full Names

Age (as of camp)

Birthday

Grade Entering this Fall (if applicable) *

T-shirt Size *

Group/Cabin Buddy Request

Preo Overnight: If registering for Camp Preo and entering grade 1 or 2, will your camper attend our special overnight camp experience on the Wednesday night of camp?

This child may receive the following medications if needed:

Tylenol
Ibuprofin
Benadryl
Dramamine

Does this child get carsick? *

Special Medical or Dietary Needs

Permission to Use Likeness: As a parent/guardian, I give CCC permission to use image(s) of this child in future advertising (brochures, website, etc.) *

Payment/Scholarship

We have never turned a camper away because of cost. You can request a full or partial scholarship on our registration form. All scholarship requests will be honored.

Camper #1 Payment

Preo full payment - $185.00
Preo half scholarship - $92.50
Camp O full payment - $285.00
Camp O half scholarship - $142.50

Camper #1 Full scholarship

I request a full scholarship for this camper

Camper #2 Payment

Preo full payment - $185.00
Preo half scholarship - $92.50
Camp O full payment - $285.00
Camp O half scholarship - $142.50

Camper #2 Full scholarship

I request a full scholarship for this camper

Camper #3 Payment

Preo full payment - $185.00
Preo half scholarship - $92.50
Camp O full payment - $285.00
Camp O half scholarship - $142.50

Camper #3 Full scholarship

I request a full scholarship for this camper

Camper #4 Payment

Preo full payment - $185.00
Preo half scholarship - $92.50
Camp O full payment - $285.00
Camp O half scholarship - $142.50

Camper #4 Full scholarship

I request a full scholarship for this camper

Total

$0.00

Select Payment Type (PayPal or Credit Card) *

Card Number

Expiration Date

Security Code

Card Holder Name

Pursuing Christ, Together

Parent/Guardian Info

Emergency Contact Info

Pediatrician's Info/Camp Agreement

CCC Camp Agreement

Camper Info 1

Camper Info 2

Camper Info 3

Camper Info 4

Payment/Scholarship

Christ Community Church exists to reflect the redeeming grace and transforming truth of Jesus Christ in a college town.