CAMP HARMONY - Camper Registration Form

Online Camper Registration consists of 2 steps:

1. Complete this informational form and print a copy of it for your records before submitting
2. Registration Deposit Payment: $25 per camp per child. (You will pay the cost of the camps you chose on the day you arrive at camp.)

NOTE: If you register online on a weekend, your registration will be processed on the following Monday morning.

Please make sure this form is completed as accurately as possible.

(*) Indicates a required field.

PART 1: Parent and Legal Guardian Information

All of these fields in PART 1 are required. If one does not apply to you, type "N/A" in the space provided.
Father's First Name *
Father's Last Name *
Mother's First Name *
Mother's Last Name *
Legal Guardian's First Name *
Legal Guardian's Last Name *

PART 2: Information About The Person Being Registered For Camp

Child's First Name *
Child's Middle Initial *
Child's Last Name *
Date of Birth *	(MM-DD-YYYY Format)
Gender *
Grade Completed *
Street Address Line 1 *
Street Address Line 2
City *
State *
Zip Code *
Phone Number *	(Include Area Code)
Church You Attend *
Pastor's Name *
Your Email Address *	NOTE: Be Sure to enter Correctly

PART 3: Camps You Are Registering For and Additional Camp Information

First Camp *
Second Camp
Third Camp
Fourth Camp
Fifth Camp
NOTE: All discounts above will be figured for you the day you arrive at camp.
Place me in a cabin with swimming lessons *
NOTE: Swimming Lessons apply ONLY to camps for Kindercritters through 5th Grade.
I want to order camp pictures *
Small Group pictures to order	(Total Quantity)
All Camp pictures to order	(Total Quantity)
Picture Prices are as follows: The first picture is $5.00. All additional pictures are $3.00 each.

PART 4: Cabin Assignment Requests and Requirements

The following 2 guidelines apply to Cabin Request Assignments: 1. There will absolutely NOT be any request changes on the day of registration. 2. The cabin request assignment MUST appear mutual on each campers regsitration form.
Assign me to the same cabin as

PART 5: Church Billing Information

NOTE: Complete PART 5 ONLY If This Section Applies To You If your congregation pays a portion of the camper registration fee, and you would like us to bill your congregation please enter the amount for each program in the space provided. You should list a camp and a dollar amount if there are multiple programs.
Camp Titles and Amount to be Billed to my Church (Ex: ROCK SOLID - $50.00)

PART 6: Summer Food Services Program - Scholarship Funds For Attending Camp

Full names of all persons living in your house
Total number of persons living in your house
Monthly Wage or Salary
Social Security
Public Assistance
Unemployment
Child Support
Pension
Other Money Received
Total

Food Stamp Case Number

AFDC Case Number

PART 7: Your Name, Todays Date, and Print Form For Your Records

Your Full Name *	(Serving as your Signature)
Today's Date *	(MM-DD-YYYY Format)

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