CRC Summer Camp

When paying online, the price of camp is raised about 3% plus .50 cents to help cover the online transaction fee.

If you desire to avoid the additional cost, CRC's office welcomes checks and cash through the mail or in-person.

The online form can still be completed and submited to the office without doing an online payment. Please mail in the $50 non-refundable deposit to the office in order to receive your confirmation letter.

Type "April15" in the Coupon Box to recieve $15 off if you pay in full by April 15.

Camper's Name *

First Name Last Name

Date of Birth: (Month, Day, Year) *

Age (at the start of camp) *

Camp Attending *

Biological Birth Sex *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cabin Mate Request #1

Cabin Mate Request #2

Parent / Guardian Name #1 *

First Name Last Name

Relationship to Camper *

Contact Information *

Cell Number: Email Address

Parent / Guardian Name #2 *

First Name Last Name

Relationship to Camper *

Contact Information *

Cell Number: Email Address

Alternate Contact Name *

First Name Last Name

Relationship to Camper *

Contact Information *

Cell Number: Email Address

In order that CRC may provide the best health care for your child during camp, please list all medications your child is currently taking. Even if your child does not regularly take any medications, this form still needs to be signed and completed. It is generally our practice to call a parent when a major medical issues arises or a camper requires more than one visit to the Nurse’s Station (e.g. injuries requiring more than simple first aid, or for headache, sore throat, etc. that does not respond to treatment.)

Camper Name *

First Name Last Name

Camp Attending *

Is your camper in general good health & able to participate in all normal camp activities? Yes or No. If No, please submit a statement of limitations. *

If necessary, please provide a statement of limitations.

All medications must be turned into the Nurse on the first day of camp and must be in the original packaging/container.

Prescription Medication: Please list and name all prescription medication, how often the medication is taken, and the reason for use. If no medication is needed, please type NA. *

Non-Prescription Medication (Vitamins, food supplements, etc): Please list and name all non-prescription medication, how often the medication is taken, and the reason for use. If no medication is needed, please type NA. *

Does your child have any dietary needs? What is the reason for the dietary needs? CRC will do our best to accommodate reasonable dietary needs. If you have questions or concerns about food allergies, camp staff encourages you to call or email the office. If no dietary needs are present, please type NA *

Any other specific allergies or treatment given? *

Date of last tetanus shot? *

Any pre-existing medical condition? *

Primary Care Physician *

First Name Last Name

Phone Number for physician *

Please enter a valid phone number.

Insurance Information: *

Insurance Company Policy Number

How do you prefer to receive your confirmation letter: *

The undersigned does hereby release, discharge, indemnify, and hold harmless Christian Retreat Center and The Allegheny and Susquehanna Conferences of the Brethren in Christ Church and all of their parent and affiliated organizations and all of their officers, agents, contractors, directors, members, participants and employees from all claims, demands, actions, judgments, and/or liabilities of whatsoever kind of nature, including any costs, attorneys’ fees, losses or expenses in connection therewith, in any way relative to, arising out of, or by reason of, my participation in, and attendance at, Christian Retreat Center and/or related facilities, including all claims or demands for death or injury to me, or any damage to, or destruction of any of my property arising out of any accident or occurrence with, said attendance, participation and/or presence, whether negligent or otherwise. This waiver, Release and Indemnification is given in consideration of, and as a condition to, permitting the undersigned to participate at Christian Retreat Center. In signing this form, I hereby certify that all information is correct and I give permission for the use of photographs, audio, and video footage including my child in camp publicly, for my child to be transported in a camp operated vehicles for approved out-of-camp activities and for purpose of medical transport, and for the release of medical records in case of illness.

Signature

Clear

If your child is attending a Pioneer Camp or Teen Camp, tier pricing is available. Please select the tier that best fits your family budget. Regardless of which tier is picked, the camp quality is the same.

Enter "April15" in the coupon box to receive $15 off the cost of camp if you pay in full on, or before, April 15th.

If you are paying via cash or check and mailing your money to the camp, please do not select a camp in the below space. Scroll down and press the submit button.

Please select your camp.

Discovery Camp Group 1 July 2-4

$ 124.10

Discover Camp Group 2 July 5-7

$ 124.10

CRC Day Camp July 3-7

$ 185.90

Pioneer Camp 8&9 July 2-7 / TIER 1

$ 335.25

Pioneer Camp 8&9 July 2-7 / TIER 2

$ 304.35

Pioneer Camp 8&9 July 2-7 / TIER 3

$ 268.30

Pioneer Camp 10&11 July 9-14 / TIER 1

$ 335.25

Pioneer Camp 10&11 July 9-14 / TIER 2

$ 304.35

Pioneer Camp 10&11 July 9-14 / TIER 3

$ 268.30

Pioneer Camp 12&13 July 16-21 / TIER 1

$ 335.25

Pioneer Camp 12&13 July 16-21 / TIER 2

$ 304.35

Pioneer Camp 12&13 July 16-21 / TIER 3

$ 268.30

Teen Camp (14-17) July 23-28 / TIER 1

$ 335.20

Teen Camp (14-17) July 23-28 /TIER 2

$ 304.30

Teen Camp (14-17) July 23-28 / TIER 3

$ 268.30

Horse Camp 1 July 9-14

$ 381.60

Horse Camp 2 July 16-21

$ 381.60

Camp on the Go! July 23-28

$ 98.35

Enter coupon

Total

$ 0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

CRC Summer Camp

Medical Form