Peace Camp 2023

Date: July 24-28, 2023

Time: 5:30 p.m. - 8:00 p.m.

Location: La Verne Church of the Brethren, 2425 E Street, La Verne, Ca, 91750

Phone: (909) 593-1364

Who: Students Entering Kindergarten - Entering 6th Grade

Mini-Peace Camp childcare for siblings and children of volunteers will be available, please indicate upon registration.

Cost: $50 per student, scholarships are available. The scholarship application can be accessed here: https://form.jotform.com/231147335055147

Deadline: Payment and Registration due July 7th
Part I: Application
Child's Name*

First NameLast Name
This registration is for a child who is the sibling of a Peace Camper or a child of a volunteer, who is between the ages of 2-4 years old, and will utilize the Mini-Peace Camp option:

Yes
Child's Age*

567891011
Child's Grade*

Kinder1st2nd3rd4th5thN/A
Child's Shirt Size*

X-SmallSmallLargeMediumX-LargeXXL
Does your child have food allergies? Yes or No. If yes, please specify.*
Parent or Guardian Name*

First NameLast Name
E-mail*
Parent/Guardian Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Emergency Contact (must be different than the parent listed) *

First NameLast Name
Emergency Contact Phone Number *

Area CodePhone Number
Parents/Guardians are encouraged to volunteer for a minimum of 2 days in the Global Village (craft center time). Please choose a minimum of two days to volunteer.*

Monday, July 24 from 7-8pmTuesday, July 25 from 7-8pmWednesday, July 26 from 7-8pmThursday, July 27 from 7-8pmFriday, July 28 from 6 - 7pm (This is an earlier time slot due to our Peace Celebration)
Group Placement - We may be able to group friends together. If there is a specific friend your child would like in his/her small group please list their name here.
Safety Statement -The La Verne Church of the Brethren may require a parent/guardian to stay with their child/ren who are disruptive or who refuse to stay with their assigned group. *
Parent/Guardian Initials
Part III: Photographic Consent
The undersigned does hereby authorize the La Verne Church of the Brethren to photograph/film (type student name):
The undersigned authorizes La Verne CoB to permit the use and display of said photographs in any publication, multimedia production, display, advertisement or WWW publication. The undersigned releases and forever discharges the LVCOB, its agents, trustees and employees from any and all claims and demands arising out of or in connection with the use of said images, including, but not limited to, any claims for invasion of privacy or defamation.
Electronic Signature of Parent/Guardian
Part III: Parent Permission/Authorization Form
I, the parent/guardian of this applicant give permission for my child to participate in Peace Camp 2023, sponsored by the La Verne Church of the Brethren from July 24-28, 2022.*
Health Insurance Provider*
Health Insurance Policy Number*
Physician Name & Phone Number*
Is your child allergic to any medications?*
Part IV: Payment
I plan to make my payment through the following platform:

Check or Cash sent to the La Verne Church of the BrethrenZellePayPalI'm planning to apply for a Peace Camp scholarship. Scholarship applications can be accessed here: https://form.jotform.com/231147335055147
Peace Camp registration cost is $50 per child. If the registration cost prevents your child from participating, please email amanda@lavernecob.org, scholarships are available. Mail your check to La Verne Church of the Brethren at 2425 E Street, La Verne, CA 91750. Please include "Peace Camp" and the name of your child in memo. Payment can also be made via Zelle. Our contact is lvcobgiving@gmail.com. Make sure to include the phrase "Peace Camp" in the notes section of your Zelle payment. PayPal is also available. Visit www.lavernecob.org and click on the PayPal button. Select Peace Camp in the dropdown menu. For any questions, email Amanda at Amanda@lavernecob.org
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

Part I: Application

Part III: Photographic Consent

Part III: Parent Permission/Authorization Form

Part IV: Payment