Registration Form
CAMPER INFORMATION
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Gender Identity
*
Please Select
Female
Male
Non-Binary
Day(s) Attending
*
Fri
Sat
Sun
Mon
CONTACT INFORMATION
The email listed below will receive a confirmation message that contains important paperwork and information regarding your camp session.
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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EMERGENCY CONTACTS
Please include at least one contact other than the listed camper and/or guardian.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Camper
*
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relation to Camper
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MEDICAL CONTACTS
Physician
*
First Name
Last Name
Hospital / Clinic
*
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mental Health Provider / Counselor
First Name
Last Name
Hospital / Clinic
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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ADDITIONAL DETAILS
Shirt Size
*
Please Select
Small
Medium
Large
XL
2XL
3XL
4XL
Lodging Request
We cannot guarantee these requests. If you know other campers who are registering and would like to room with them, please include their name(s) here.
Dietary Needs or Restrictions
Please be aware that our food may contain or come into contact with common allergens, such as dairy, eggs, wheat, soybeans, tree nuts, peanuts, fish, shellfish or wheat. While we take steps to minimize risk and safely handle the foods that contain potential allergens, please be advised that cross contamination may occur, as factors beyond our reasonable control may alter the formulations of the food we serve, or manufacturers may change their formulations without our knowledge.
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PERMISSIONS
Camp Burton has permission to video/photograph the camper for...
promotional use
the digital photo album
Signature
*
Date
*
-
Month
-
Day
Year
Date
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PAYMENT
Select what you would like to pay today (includes 4% processing fee):
*
Non-Refundable Deposit ($52.00)
Full Tuition Cost
Payment Selection
Please select a method for paying the remaining amount due.
I will pay by mail or in-person using check, cash, or card
I would like DSHS/DDA to be billed for the remaining fees
I would like to request a campership
Paying By Mail or In-Person
Camp Burton will send an invoice to the main contact email listed on or around June 15. This invoice will document today's payment and show the remaining tuition balance due on or before the first day of your camp session.
DSHS/DDA Contact
Name
First Name
Last Name
Email
example@example.com
Campership Request
It is part of our mission to make summer camp accessible to all regardless of a camper’s financial situation. We encourage you to request assistance if you need it. Financial aid typically goes to those who have many dependents or are facing financial hardship. This process is honor-based and confidential. Our funds are limited, we might not be able to grant every financial aid request.
How much can be paid towards the remaining tuition amount?
Minimum: $50 non-refundable deposit
Does the camper/family receive any other benefits (SNAP, DSHS, etc.)?
Yes
No
Please provide us with any other information you think we should know.
Today's Total
*
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( X )
USD
Description
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Submit
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