CCBPS Summer Camp 2026 Application Packet

CCBPS Summer Camp 2026 Application Packet

Thank you for your interest in enrolling your child in the CCBPS Summer Camp 2026! We are excited to offer a fun, safe and enriching environment for students to learn, grow and explore throughout the summer.
Camper Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Age
Grade (Fall 2026)
Grade (Fall 2026)
School:
Name of School
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Information
Parent/Guardian Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Alternate Contact Full Name

First NameLast Name
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
1. Emergency Contact Name (other than parent/guardian)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2. Emergency Contact Name (other than parent/guardian)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Does the camper have any allergies?
If yes, please list allergies:
Does the camper take any medications?
If yes, please list medications and instructions:
Doctor's Name
Phone Number
Permissions and Agreements
I give permission for my child to participate in the Cornerstone Community Based Programs Summer Camp 2026. I understand that all activities are supervised and agree to release Cornerstone Community Based Programs from liability in case of minor injuries.
I authorize staff to seek emergency medical treatment if necessary.
I consent to the use of photos/videos of my child for camp promotional purposes.
Camper Behavior Agreement: Campers are expected to respect staff and peers, follow directions, participate positively, and keep hands and feet to themselves.
Payment Agreement: I agree to pay a Program Fee of $200 per camper which includes $50 Non-Refundable Fee.
Payment Agreement: Program Fee $200 per camper Includes $50 Non-Refundable Application Fee
Payment Method:
Parent/Guardian Signature
Should be Empty:

CCBPS Summer Camp 2026 Application Packet

Camper Information

Parent/Guardian Information

Emergency Contact

Medical Information

Permissions and Agreements