Home
Camps
Summer Camp
Winter Camp
Family Camp
Adult Retreat
Online Registration
Summer Camp Registration
Adult Retreat Registration
Donate
Rentals
Rental Calendar
Rental Request Form
Rental Price Calculator
Join Our Team
Full Time Staff Application
Volunteer Application
Contact
Summer Registration
Week of Camp
School Grade Child Completed
Select...
1
2
3
4
5
6
7
8
9
10
11
12
Week of Camp
Select...
Mini Camp (Completed 1st & 2nd Grades)
Elementary Camp (Completed 3rd & 4th Grades)
Middler Camp (Completed 5th & 6th Grades)
Jr. High Camp (Completed 7th & 8th Grades)
Sr. High Camp (Completed 9, 10, 11 & 12th Grades)
Parent attending with child?
Yes
No
Price:
200
Camper Information
First Name
Last Name
Birthdate
Email Address
(Optional)
Address
City
State
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
Zip
Gender
Male
Female
Home Church
Select...
No Church Specified
Attends Another Church
Agora Church
Albion Brethren
Beacon of Hope
Five Stones Community
Fremont Brethren
Garber Brethren
Gratis Brethren
Gretna Brethren
New Lebanon Brethren
North Georgetown
Park Street Brethren
Pleasant Hill Brethren
Pumphouse Ministries
Radial Church
Smithville Brethren
Smoky Row Brethren
Transformed Life Center
Trinity Brethren
United Community, Dayton
Vineyard Community Church
West Alexanderia Brethren
Williamstown Brethren
Parent/Guardian Information
Confirmation receipt will be sent to Parent/Guardian Email Address.
Parent/Guardian Name
Parent/Guardian Email Address
Primary Phone #
Alternate Phone #
(Optional)
Emergency Contact Name
Emergency Contact Phone #
Reoccurring Conditions
Please check all that apply:
Asthma
Allergies
Bed Wetting
Diabetes
Ear Aches
Fainting
Hay Fever
Seizures
Sleep Walking
Upset Stomaches
Medications
Allow my child to be given the following medications
if necessary
:
Ibuprofen
(Motrin)
Acetaminophen
(Tylenol)
Naproxen
(Aleve)
Antacids
(Tums)
Diphenhydramine
(Benadryl)
Are Immunizations Current
Date of Last Tetanus
(Optional)
All medication must be given to the camp staff upon arrival. All medications should be kept in the original labeled container with the medication name, dosage, and directions clearly indicated on the container. Please use the following spaces to list any health related issues including specific allergies, food allergies, relevant surgeries, physical limitations, or other serious illnesses along with any special treatments or concerns. Please be specific.
Current Medications or Food Allergies
Special Instructions
Signature
I hereby give permission for emergency medical treatment, including hospitalization, injections, anesthesia, or surgery to the camper named above if such is deemed necessary while attending Camp Bethany. I understand that in the case of emergency, every effort will be made to contact me, but given the situation that I cannot be reached Camp Bethany has permission to act on my behalf. I also give permission for the camper named to be photographed and/or video recorded for promotional purposes.
By filling in the box below, I accept that this will serve as my signature for the electronic document or record.
Parent or Legal Guardian Signature