Greenbrier Christian Camp Registration

Registering as a church groupRegistering as an individual
Week you are registering for:*
NOTE all fields are required.
Camper Information
First Name*
Last Name*
Home Church*
School*
Age at Camp Time*
Grade at Camp Time*
Birthday*
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address
Address Line 1
City
State
Zip
Parent / Guardian Information

(Only 1 required)
First Name*
Last Name*
Relationship to Camper*
Primary Contact Phone*
Please enter a valid cell number.Format: (000) 000-0000.
Email*
email@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Emergency Contact Information:
Primary Emergency Contact*

First NameLast Name
Primary Emergency Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency Email*
email@example.com
Relationship to Camper*
Primary contact's relationship to camper
Secondary Emergency Contact*

First NameLast Name
Secondary Emergency Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Email*
example@example.com
Relationship to Camper*
Secondary contact's relationship to camper
Medical Information
Camper Physician*
Physician's Phone*
Format: (000) 000-0000.
YesNo
YesNo
Medications taken regularly*
Reason for taking medication*
Health or Behavioral concerns that you would like our staff to know about your child?*
Enter 'none' if not applicable.
Please list child's allergies (drug or other).*
Enter 'none' if not applicable.
Please list any medication child requires in case of an allergic reaction.*
Enter 'none' if not applicable.
Dietary needs / restrictions*
Enter 'none' if not applicable.
Pre-existing conditions*
Enter 'none' if not applicable.
Insurance Information
Insurance Company Name*
Policy / Group ID*
Insurance Cardholder Name*
I DO NOT WISH MY CHILD TO PARTICIPATE IN:*
Enter 'no restrictions' if not applicable.
Church Name*
What church group are you coming with?
Youth Pastor / Head Camp Counselor*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Church Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list the name and age for each person.
Other Sponsors & Campers Accompanying
Number of Male Campers*
Number of Female Campers*
Number of Adult Male Chaperones / Sponsors*
Number of Adult Female Chaperones / Sponsors*
Total Number in Party
Church City
In which city is your church?
Church State
In which state is your church?
I have read the general information and agree to support Greenbrier Christian Retreat in the dress and conduct regulations for my child. I also give permission for my child to attend and to use photos and video that include the camper in camp publicity. In case of medical emergency, I understand that every effort will be made to contact parents or guardians of campers. In the event I cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize and secure proper treatment for my child. I agree to the transportation of my child for activities at Greenbrier Christian Retreat.
Date*

MonthDayYear
Date
Parent / Guardian Signature*

Clear
Camp Fees
- The full cost for campers and chaperones/counselors is $225 if registered on or before March 1st and $250 if registered after March 1st.
- If registering on or before March 1st, a non-refundable, pre-registration fee of $75 per person is due by March 1st. The balance of $150 per person is due by May 22th.
- If registering after March 1st, payment in full ($250) is due by May 22th.
- Registered Church’s Pastor and Pastor’s Wife – FREE!
- For every 15 paying campers you get 1 camper/Counselor/Chaperone – FREE
Registration Policies
- An individual Camper Registration form must be completed by all campers. This can be done online or via a printable version. Please direct campers to our website – greenbrierchristianretreat.com under the 2026 Summer Camp tab.
- All forms and payments must be completed and submitted by May 22nd.
Online Payment*

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USDPayment in full is required in order to submit registration.
"And of some have compassion, making a difference." - Jude 1:22
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NOTE all fields are required.

Camper Information

Parent / Guardian Information

Medical Information

Insurance Information

Camp Fees

Registration Policies