Junior Week 2025

Junior Week

Please fill out 1 form per camper. Thank you!
Camper's Name*

First NameLast Name
Camper's Gender*
T-Shirt size*
Will Camper be commuting?*
Drop off would be at 8am and pickup would be at 9pm.There will be no discount for this type of enrollment.
Camper's Date of Birth*

MonthDayYear
Age (as of camp week)*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address where you'd like to receive confirmation and information*
example@example.com
Who is the primary contact in case of emergency?*
Father's Name

First NameLast Name
Father's Cell Phone Number
Mother's Name

First NameLast Name
Mother's Cell Phone Number
Stepparent/Guardian's Name

First NameLast Name
Stepparent/Guardian's Cell Phone Number
Liability & Off Camp Release PDF

Camp Policy Letter PDF
After reading both documents above,*

I, the parent/guardian, have read and agree to the Liability Release, Off Camp Release, & Camp Policy letterI, the camper, have read and agree to the Liability Release, Off Camp Release, & Camp Policy letter
Permission to Use Video/Photos*

I give permission for Camp Ephachiseca to use video or photos of the camper I am registering for promotional purposes.I DO NOT give permission for Camp Ephachiseca to use video or photos of the camper I am registering for promotional purposes.

Billing
How would you like to pay?*
The camp is charged an online processing fee. The online prices have reflected this fee.
Home Church:*
Sending Check: Total Cost of Camp
USD
Enter Church Discount Code
****Please ask your church for your discount code.****
Please mail a check immediately in this amount to: Eastern PA Christian Service Assembly 155 Camp Road, Bloomsburg, Pa 17815
USD

I will pay Debit or Credit

Junior WeekGrades 3-5 July 13-19

$262.70

Enter coupon

By entering your name below, you are electronically signing this form and verifying that:

1. All information is accurate to the best of your knowledge.

2. I have read and will honor the cell phone and electronic devices policy.
Parent/Guardian Signature*

First NameLast Name
Camper Signature*

First NameLast Name
Date of Electronic Signatures*

MonthDayYear
Date
Should be Empty:

Junior Week