Peace Camp 2024 Registration

Peace Camp Houston Registration 2024

For the protection of all participants, Peace Camp will follow stringent safety protocols. We will monitor public health alerts and follow close-down advisories.

All staff and the families of campers will be alerted immediately of outbreaks, potential exposures, and consequent closures or cancellations.

Refunds of registration fees will be prorated based on the number of days cancelled.

All Camp Sessions are Monday through Friday, 9 AM - 3:00 PM*.

*After-Camp Care Hours will be available if requested in advance.

Location 1:	Servants of Christ United Methodist Church
	3827 Broadway St.
	Houston, TX 77017
Dates:	June 10-14
Ages:	6 years Through 12th grade

Campers will be grouped in order to participate in age-appropriate activities.

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Location 2: Houston Mennonite Church
1231 Wirt Rd
Houston, TX 77055

July 10-12 will be for age 6 years through 6th grade. NOTE: This was originally to be July 8-12, but due to Tropical Storm Beryl, July 8 and 9 will not be camp days. However, there WILL be Peace Camp Wed-Fri. July 10-12, and the hours have been extended for those days (9am - 4:30pm).

Please see the main Peace Camp web page (below) for more updates.

July 22-26 will be for 7th grade through 12th grade

Peace Camp is a non-religious event.

For more information and updates, see www.hpjc.org/peace-camp

Before beginning registration, please scroll through the form to see what information you will need to have at hand to register your children. Also please read about the registration fees/scholarship information AND the permissions information.

The registration fee is $200 for ages 6 years-6th grade and $100 for 7th grade - 12th grade.

IMPORTANT NOTE: All are welcome, regardless of ability to pay. Plenty of scholarships are available.

To request discounted fees or scholarship, please call Cheryl Crosier at 713 515-6370 or send an email message to her at cheryl@crosierbiomed.com

If your child or children have been approved for discounted fees or scholarships, ignore the fees indicated below for each camper.

You may register up to three children/teens below.

All children/teens ("Campers") registered below must have the same:

parent guardian/emergency contact information
authority to grant permissions
physician information
authorized pick-up information.

If any of these items do not pertain to each camper registered below, please submit separate registrations.

Please Note: Email addresses will be added to the Houston Peace & Justice Center's email list, but not shared with any other organization. You may easily unsubscribe from HPJC's email list by scrolling to the bottom of the messages and clicking on the link to change your options or you may make a note in the registration requesting that your email addresses not be added to HPJC's list.

First, please tell us how many campers you are registering for Peace Camp now with this form. If you need to register more than three, please open and complete another registration form.

How many children are you registering now?*

123

Camper #1 Information:

Camper #1 Full Name*

First NameLast Name

Camper #1 Grade in Fall of this year*

Camper#1 Birth Date*

MonthDayYear

Which week(s) will Camper #1 attend camp?*

June 10-14 at Servants of Christ United Methodist Church (all grades)July 8-12 at Mennonite Church (only for age 6 years through 6th grade)July 22-26 at Mennonite Church (only for 7th grade through 12th grade)

Please correct either grade or week of camp above - July 8-12 is only for age 6 years through 6th grade.

Camper #1 T-Shirt Size*

For Camper #1. Please list allergies and/or chronic conditions, or anything else we should know. If you do not need to list information, please enter "NONE"*

Month and Year of Camper #1's Last Tetanus Booster? Tetanus vaccination is not required, but in case of injury, medical providers will request Tetanus vaccination status

Will Camper #1 need AFTER-CAMP care?*

YESNO

Camper #1 Fees*

Camper #2 Information:

Camper #2 Full Name*

First NameLast Name

Which grade will Camper #2 be in Fall of this year?*

Camper#2 Birth Date*

MonthDayYear

Which week(s) will Camper #2 attend camp?*

June 10-14 at Servants of Christ United Methodist Church (all grades)July 8-12 at Mennonite Church (only for age 6 years through 6th grade)July 22-26 at Mennonite Church (only for 7th grade through 12th grade)

Camper #2 T-Shirt Size*

For Camper #2. Please list allergies and/or chronic conditions, or anything else we should know. If you do not need to list information, please enter "NONE"*

Month and Year of Camper #2's Last Tetanus Booster? Tetanus vaccination is not required, but in case of injury, medical providers will request Tetanus vaccination status

Will Camper #2 need AFTER-CAMP care?*

YESNO

Camper #3 Information:

Camper #3 Full Name*

First NameLast Name

Which grade will Camper #3 be in Fall of this year?*

Camper #3 Birth Date*

MonthDayYear

Which week(s) will Camper #3 attend camp?*

June 10-14 at Servants of Christ United Methodist Church (all grades)July 8-12 at Mennonite Church (only for age 6 years through 6th grade)July 22-26 at Mennonite Church (only for 7th grade through 12th grade)

Camper #3 T-Shirt Size*

For Camper #3. Please list allergies and/or chronic conditions, or anything else we should know. If you do not need to list information, please enter "NONE"*

Month and Year of Camper #3's Last Tetanus Booster?Tetanus vaccination is not required, but in case of injury, medical providers will request Tetanus vaccination status

Will Camper #3 need AFTER-CAMP care?*

YESNO

Emergency Contact & Parent/Guardian Information

NOTE: At least one parent/guardian along with contact information must be furnished. If two parent/guardians are furnished, both must pertain to each camper you are registering. If the parent/guardian information differs for the campers you wish to register, please register those campers separately.

First Parent/ Guardian Name*

First NameLast Name

First Parent/ Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

First Parent/ Guardian Phone at which we will be able to reach you during camp hours.*

Day Phone

Evening Phone

First Parent/ Guardian email address*

example@example.com

(If 2nd parent/guardian information is not applicable, skip down to "Authorized to pick up")

Second Parent/ Guardian Name

First NameLast Name

Second Parent/ Guardian Address (put "same" if applicable)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Second Parent/ Guardian Phone Number at which we can reach second parent/guardian during camp hours

Day Phone

Evening Phone

Second Parent/ Guardian E-mail address

example@example.com

AUTHORIZED TO PICK UP

Persons, other than those listed above, to whom your camper(s) may be released:

To help us identify persons who can pick up your campers, please enter a word or short phrase for these to use at camp pick-up. Make sure those who are authorized to pick-up your campers know this word or short phrase.*

May Pick up: Name, relationship to Camper(s), phone(s)

MEDICAL INFORMATION

The listed physician/contact information must pertain to each camper registered above. If physician information is not the same for each camper, please register the camper(s) in separate registration sessions.

Physician's Name*

First NameLast Name

Physician's Phone*

Permission to Participate

In order for child(ren) to participate, Peace Camp Houston must have a record that his/her/their parents/guardians have authorized that participation and furnished accurate information.

If you decline the use of your child(ren)'s photographic images on promotional material, your child(ren) will still receive a printed, participation certificate that will show photographs (including your camper's) identified with first names of all participants for the session attended.

Permission Statement

Please check all applicable boxes. Please furnish any explanations and exceptions to these items in the "Explanation Notes" block below. If Peace Camp Houston is not able not accomodate the exceptions you list, your registration fees will be returned in full.

I hereby certify:*

I give permission for my child(ren) to participate in all peace camp activities.The child(ren) listed above is(are) in good health.The information submitted in this registration is true and accurate.I give my permission for my child(ren) to be photographed and/or video recorded and that resulting images of the child(ren) may be used in brochures and internet promotions for Peace Camp Houston without name identification of the child(ren).I give my permission for my child(ren) to be transported and treated in case of a medical emergency.I understand that even with adherence to safety protocols, exposure to communicable diseases is a risk and that Peace Camp's liability coverage does not include communicable diseases.

Permissions Explanation Notes

Form Information and Permissions Authentication

Please use the electronic signature box below to certify that the information in this form is true to the best of your knowledge and that give the permissions checked above regarding your child participation in Peace Camp Houston.

Click or tap in the box and use your mouse, track pad, or fingertip (on touch screens such as tablets and smart-phones) to write your signature.

Signature*

Cancellations

If you must cancel Peace Camp reservations for your child(ren) please let us know as soon as possible. Please leave a message at 713 515-6370 or email Cheryl Crosier cheryl@crosierbiomed.com.

Peace Camp Fees and Scholarships

Peace Camp Registration Fee

It costs a significant amount to provide the peace camp experience. The recommended fee is $200 per child and $100 per teen, per week.

Scholarships

Fundraisers and donations make it possible for us to provide a limited number of full and partial scholarships for those of slender means.

If you cannot pay the full amount, please pay what you can, by entering that amount below. If you can pay more later, please do so. Please understand that if fundraisers do not provide enough funds, that scholarships will be limited. You may also pay by credit or debit card, or by mailing in a check. See mailing information below.

Recommended registration payment based on $200 per child and $100 per teen.

Payment & Scholarship Options*

I will pay the recommended registration payment listed above for campersI have made arrangements to pay discounted registration(s) payment.I have made arrangements for my camper(s) to be on scholarships.

Fill in the Actual Amount you are paying (total for all of your children)

Dollar amount

Additional Donation to help provide scholarships for other children (optional)

Total Non-Discounted Fees and additional donation*

I will pay by:*

Debit or credit card nowCheck or money order that I will mail inNot applicable - My child(ren) have been approved for full scholarship(s)

Total to pay (calculated)

Calculation for credit card

Total for Payment by Credit/Debit Card or Check

Paying by Check or Money Order - Please Read Carefully!

To pay by check:

Make your check payable to "Houston Peace and Justice Center"
Indicate "Peace Camp Registration" with the camper's name(s) on the memo line.
Click "PRINT FORM" button below to PRINT THE THIRD PAGE OF THIS FORM, then CLICK "SUBMIT" below so we'll get the information electronically, and
MAIL BOTH THE PRINTED page & YOUR CHECK to:HPJC, PO BOX 66234, Houston, TX 77266

Paying by Debit or Credit Card

To pay registration fees online, please enter your name and other card information below exactly as shown on your credit or debit card.

We use Stripe.com to securely process credit and debit cards, and we never see your card number. Your credit card or debit statement will show that payment was made to "HPJC" which is Houston Peace and Justice Center, the sponsor for Peace Camp Houston.

You will receive two email messages: one confirming the registration and one confirming the payment.

Please Remember to click on the SUBMIT button at the end of this form. If you do not see a confirmation page beginning with a pink THANK YOU the registration process has not been completed.

Credit/Debit card amount for Peace Camp

USDPeace Camp total amount

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration