Peace Camp Houston 2019 Registration

Peace Camp Houston Registration 2019

Each Camp Session is Monday through Friday, 9 AM - 3:00 PM*.

*After-Camp Hours will be available only at the Mission Milby location. See details below.

2019 Dates and Locations

- June 3-7 Houston Mennonite Church, 1231 Wirt Rd. Houston, TX 77055 THIS SESSION IS COMPLETED.

- June 17-21 Mission Milby Community Center, 2220 Broadway Street 77012 THIS SESSION IS COMPLETED.

- July 15-19 Cameron Retreat Center, 2405 Holcombe Blvd. Houston, TX 77021 THIS SESSION IS COMPLETED.

- July 29-Aug 2 First Unitarian Universalist Church, 5200 Fannin, Houston, TX 77004

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. Please note the regular registration fee is $185 per child for each camp session.

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 and teens ("Campers") registered below must have the same parent guardian/emergency contact information, authority to grant permissions, physician information and authorized pick-up information. If any of these items do not pertain to each child/teen registered, 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.

Junior Counselor Program: Children and teens who will be in seventh grade or higher this fall will be Junior Counselors. Junior Counselors will participate in an age-appropriate program as well as assist camp staff, and receive a letter confirming service hours at the conclusion of camp. Only a limited number of Junior Counselors will be accepted for each Peace Camp Session. The regular registration fee for Junior Counselors is $50 to help cover program materials, t-shirt, and snacks.

Camper #1 Information:

Camper #1 Full Name *

First Name Last Name

Which grade will Camper #1 be in Fall 2019? *

Camper#1 Birth Date

Month Day Year

Camper #1 T-Shirt Size

For Camper #1. Please list allergies and/or chronic illnesses, or anything else we should know.

Month and Year of Camper #1's Last Tetanus Booster?

Camper #1 Sex

Male Female

Which Session(s) will Camper #1 attend? *

NO LONGER AVAILABLE June 3-7, 2019 at Houston Mennonite Church, 1231 Wirt Rd. Houston, TX 77055 NO LONGER AVAILABLE June 17-21, 2019 at Mission Milby Community Center, 2220 Broadway Street, Houston, TX 77012. SESSION IS FULL July 15-19 2019 Cameron Retreat Center, 2405 Holcombe Blvd. Houston, TX 77021 July 29-Aug 2, 2019 First Unitarian Universalist Church, 5200 Fannin, Houston, TX 77004

Camper #1 will be present for AFTER-CAMP hours. (Offered only June 17-21, Mission Mission Milby Community Center)

NO YES

Camper #1 Fees

Camper #2 Information:

Camper #2 Full Name

First Name Last Name

Which grade will Camper #2 be in Fall 2019?

Camper#2 Birth Date

Month Day Year

Camper #2 T-Shirt Size

For Camper #2. Please list allergies and/or chronic illnesses, or anything else we should know.

Month and Year of Camper #2's Last Tetanus Booster?

Camper #2 Sex

Male Female

Which Session(s) will Camper #2 attend?

NO LONGER AVAILABLE June 3-7, 2019 at Houston Mennonite Church, 1231 Wirt Rd. Houston, TX 77055 NO LONGER AVAILABLE June 17-21, 2019 at Mission Milby Community Center, 2220 Broadway Street, Houston, TX 77012. SESSION IS FULL July 15-19 2019 Cameron Retreat Center, 2405 Holcombe Blvd. Houston, TX 77021 July 29-Aug 2, 2019 First Unitarian Universalist Church, 5200 Fannin, Houston, TX 77004

Camper #2 will be present for AFTER-CAMP hours. (Offered only June 17-21, Mission Mission Milby Community Center)

NO YES

Camper #2 Fees

Camper #3 Information:

Camper #3 Full Name

First Name Last Name

Which grade will Camper #3 be in Fall 2019?

Camper#3 Birth Date

Month Day Year

Camper #3 T-Shirt Size

For Camper #3. Please list allergies and/or chronic illnesses, or anything else we should know.

Month and Year of Camper #3's Last Tetanus Booster?

Camper #3 Sex

Male Female

Which Session(s) will Camper #3 attend?

NO LONGER AVAILABLE June 3-7, 2019 at Houston Mennonite Church, 1231 Wirt Rd. Houston, TX 77055 NO LONGER AVAILABLE June 17-21, 2019 at Mission Milby Community Center, 2220 Broadway Street, Houston, TX 77012. SESSION IS FULL July 15-19 2019 Cameron Retreat Center, 2405 Holcombe Blvd. Houston, TX 77021 July 29-Aug 2, 2019 First Unitarian Universalist Church, 5200 Fannin, Houston, TX 77004

Camper #3 will be present for AFTER-CAMP hours. (Offered only June 17-21, Mission Mission Milby Community Center)

NO YES

Camper #3 Fees

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 registerting. If the parent/guardian information differs for the campers you wish to register, please register those campers separately.

First Parent/ Guardian Name *

First Name Last Name

First Parent/ Guardian Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

First Parent/ Guardian Cell Phone *

Day Phone

Evening Phone

First Parent/ Guardian Email *

example@example.com

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

Second Parent/ Guardian Name

First Name Last Name

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

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Second Parent/ Guardian Cell Phone

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:

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 Name Last Name

Physician's Phone *

Permission to Participate

In order for child(ren)/teen(s) 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/teen's photographic images on promotional material, your child(ren)/teen(s) will still receive a printed, participation certificate that will show photographs 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)/teen(s) to participate in all peace camp activities. The child(ren)/teen(s) 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)/teen(s) to be photographed and/or video recorded and that resulting images of the child(ren)/teen(s) may be used in brochures and internet promotions for Peace Camp Houston without name identification of the child(ren)/teen(s). I give my permission for my child(ren)/teen(s) to be transported and treated in case of a medical emergency.

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/teen's 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 *

Clear

Cancellations

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

No refunds will be made for cancellations received three days or less before the beginning of a camp session because funds will have already been committed for staffing and materials.

Please see the table above for cancellation deadlines.

Peace Camp Fees and Scholarships

Peace Camp Registration Fee

It costs a significant amount to provide the peace camp experience. The recommended fee is $185 per child, per week. The recommended registration fee for Junior Counselors (grade 7-12) is $50 per teen.

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.

To check if scholarships are still available, please call Cheryl Crosier at 713 515-6370 or send an email message to her at cheryl@crosierbiomed.com

Recommended registration payment based on $185 per child per week (for children in grades K-6). For each teenage Junior Counselors (grades 7-12), the recommended payment includes $50 per week.

Payment & Scholarship Options *

I will pay the recommended registration payment listed above for campers in grade K-6 grades. ($50 for each teenage Junior Counselor per session.) I have made arrangements to pay discounted registration(s) payment. I have made arrangements for my camper(s)/teen(s) to be on scholarships.

Discounted 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

I will pay by:

Debit or credit card now Check or money order that I will mail in Not applicable - My child(ren) have been approved for full scholorship(s)

Total to pay (calculated)

Total for Credit Card payment

Paying by Check or Money Order - Please Read Carefully!

To pay by check:

Make your 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 THIS ENTIRE FORM, then CLICK "SUBMIT" below so we'll get the information electronically, and
MAIL BOTH THE PRINTED FORM & 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.

Total Dollar Amount for Peace Camp (calculated)

USD Total Amt

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

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

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.