Breakaway Teen Camp 2025
Parent / Guardian Name:
*
First Name
Last Name
Parent / Guardian E-mail:
*
example@example.com
Parent / Guardian Cell:
*
Number of students attending:
*
Student 1 Name:
*
First Name
Last Name
Age of student 1:
*
Gender at birth:
*
Please Select
Female
Male
Check one:
*
Please Select
Middle School
High School
Youth Leader
Student 2 Name:
First Name
Last Name
Age of student 2:
Gender at birth:
Please Select
Male
Female
Middle or High School:
Please Select
Middle School
High School
Student 3 Name:
First Name
Last Name
Age of student 3:
Gender at birth:
Please Select
Female
Male
Middle or High School:
Please Select
Middle School
High School
My Products
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Initial Deposit per student.
Deposits are due by June 1st.
$
100.00
Quantity
1
2
3
4
5
6
7
8
9
10
Remaining Portion of Initial Deposit per student.
For families completing their payment after the initial deposit. Due July 1st.
$
139.00
Quantity
1
2
3
4
5
6
7
8
9
10
Full Registration per student.
Full Registration cost is due by July 1st.
$
239.00
Quantity
1
2
3
4
5
6
7
8
9
10
High Ropes
Only select High Ropes if you initially registered your student with it.
$
30.00
Quantity
1
2
3
4
5
6
7
8
9
10
T-Shirt
Only select T-Shirt if you initially registered your student with it.
$
20.00
Quantity
1
2
3
4
5
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
The undersigned shall be liable & agrees to pay all cost & expenses incurred in connection with such medical & dental services rendered to the aforementioned student(s) pursuant to this authorization. Should it be necessary for my student(s) to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does hereby give permission for my student(s) to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Stone Creek Church and Illinois Student Ministries.
*
Signature Needed for Travel Consent
Submit
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