Camp Barnabas Registration
Child's Name
*
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age Range
6 - 9 years old
10 - 12 years old
Gender
Female
Male
Other
2nd Child's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age Range
6 - 9 years old
10 - 12 years old
Gender
Female
Male
Other
3rd Child's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Age Range
6 - 9 years old
10 - 12 years old
Gender
Female
Male
Other
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Parent / Guardian
1st Parent/Guardian
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
2nd Parent/Guardian
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1 Phone Number
*
-
Area Code
Phone Number
Emergency Contact 2
First Name
Last Name
Emergency Contact 2 Phone Number
-
Area Code
Phone Number
The following are authorized for pick up:
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Signature/Deposit
Please List Any Allergies/Medical Condition(s):
*
Please select all that apply:
My child/children will be attending Before Care (8:00am - 9:00am)
My child/children will be attending After Care (3:00pm - 5:00pm)
My child/children will not be attending Extended Care
Media Release
I authorize, without compensation, the use by St Lukes Episcopal Church, Germantown of me or my minor child/ward's image and/or voice recordings relating to and occurring during the period of my participation in the Program. This authorization includes permission to reproduce, publicize, broadcast or display my visual images or voice recordings, with or without my name, and without any form of compensation for the use of my images, name or voice recordings, throughout the world, an unlimited number of times in perpetuity in any and all media, now known or hereafter invented.
I do not authorize the use by St Lukes Episcopal Church, Germantown of me or my minor child/ward's image and/or voice recordings relating to and occurring during the period of my participation in the Program. This authorization includes permission to reproduce, publicize, broadcast or display my visual images or voice recordings, with or without my name, and without any form of compensation for the use of my images, name or voice recordings, throughout the world, an unlimited number of times in perpetuity in any and all media, now known or hereafter invented.
Media Release
*
By signing, I acknowledge that this electronic signature serves as a valid representation of my signature for all purposes, including legally binding contracts, just like a wet ink signature on paper.
Please verify that you are human
*
Two-week deposit required: $185 per week for Regular Camp (20% off total for families with multiple children)
*
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Camp Deposit
$
370.00
A 20% discount for families with multiple children will be applied.
Number of Children
1
2
3
Item subtotal:
$
0.00
Enter coupon
Apply
Total
$
0.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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