Greenbrier Christian Camp Individual Registration

Week you are registering for:*
NOTE all fields are required.
Camper Information
First Name*
Last Name*
Home Church*
School*
Age at Camp Time*
Grade at Camp Time*
Birthday*
MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Guardian Information

(Only 1 required)
First Name*
Last Name*
Relationship to Camper*
Primary Contact Phone*
Please enter a valid cell number.Format: (000) 000-0000.
Email*
email@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information:
Primary Emergency Contact*

First NameLast Name
Primary Emergency Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency Email*
email@example.com
Relationship to Camper*
Primary contact's relationship to camper
Secondary Emergency Contact*

First NameLast Name
Secondary Emergency Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Email*
example@example.com
Relationship to Camper*
Secondary contact's relationship to camper
Medical Information
Camper Physician*
Physician's Phone*
Format: (000) 000-0000.
YesNo
YesNo
Medications taken regularly*
Reason for taking medication*
Health or Behavioral concerns that you would like our staff to know about your child?*
Enter 'none' if not applicable.
Please list child's allergies (drug or other).*
Enter 'none' if not applicable.
Please list any medication child requires in case of an allergic reaction.*
Enter 'none' if not applicable.
Dietary needs / restrictions*
Enter 'none' if not applicable.
Pre-existing conditions*
Enter 'none' if not applicable.
Insurance Information
Insurance Company Name*
Policy / Group ID*
Insurance Cardholder Name*
I DO NOT WISH MY CHILD TO PARTICIPATE IN:*
Enter 'no restrictions' if not applicable.
Date*

MonthDayYear
Date
Parent / Guardian Signature*

Clear
Camp Fees
The full cost for campers is $225 if registered on or before March 31st and $250 if registered after March 31st.
Registration Policies
- An individual Camper Registration form must be completed by all campers. This can be done online or via a printable version. Please direct campers to our website – greenbrierchristianretreat.com under the 2026 Summer Camp tab.
- All forms and payments must be completed and submitted by May 22nd.
YesNo
Please pay in full to complete registration.
Please pay your portion to complete registration.

(If required, otherwise leave payment field empty and submit)
Online Payment

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USDEnter payment amount. Payment will be initiated in the next step.
"And of some have compassion, making a difference." - Jude 1:22
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NOTE all fields are required.

Camper Information

Parent / Guardian Information

Medical Information

Insurance Information

Camp Fees

Registration Policies