Greenbrier Christian Camp Registration

What type of registration is this?*

Registering as a church groupRegistering as an individual
Week you are registering for:*
Name of Responsible Party
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please list the name and age for each person.
Other Sponsors & Campers Accompanying
Number of Male Campers
Number of Female Campers
Total Number in Party
Church Name
What church group are you coming with?
Church City
In which city is your church?
Church State
In which state is your church?
When registering a group, please note that upon arrival to camp, each camper must present an individual camper form with complete contact, medical, & emergency information. The printable form can be found here: Camper Form
Camper Information
Name
Birthday
Age
Gender

MaleFemale
Address
City
State
Zip
Email
example@example.com
Home Phone
Cell Phone
Please enter a valid cell number.
Grade for upcoming school year
Medical Information
Camper Physician
Phone
Campers must be immunized against: Mumps, Measles, Whooping Cough, Polio, Diphtheria, Rubella, Tetanus
Tetanus current?

YesNo
Medications taken regularly
Reason for taking medication
Health or Behavioral concerns that you would like our staff to know about your child
Drug allergies or other allergic reactions
Dietary needs / restrictions
Pre-existing conditions
Parent / Guardian Information

(Only 1 required)
Name
Relationship to Camper
Email
example@example.com
Emergency Contact Phone Numbers:
Primary emergency phone
Please enter a valid phone number.
Secondary emergency phone
Please enter a valid phone number.
Insurance Information
Insurance Company Name
Policy / Group ID
Cardholder Name
I DO NOT WISH MY CHILD TO PARTICIPATE IN:
I have read the general information and agree to support Greenbrier Christion 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 Christion Retreat. I have read and agree to the Individual Consent and Release Agreement.
Date

MonthDayYear
Date
Parent / Guardian Signature

Clear
Camp Costs
Junior Week: $250* per camper and sponsor

Teen Week: $250* per camper and sponsor

*Early Bird price is discounted to $225 if registering by March 31.
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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Camper Information

Medical Information

Parent / Guardian Information

Insurance Information

Camp Costs