2024 Summer Peace Camper Registration Form

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Peace Camp For Kids Summer 2024

When: June 24-28, 2024 -- 9 AM to 3 PM

Who: Children entering Kindergarten through eighth grade in the 2024-25 school year are eligible for Summer Peace Camp 2024.

Where: Gather Community Space at First Presbyterian Church, 97 South Franklin Street in Wilkes-Barre, Pennsylvania

Fees: $125 per child (Payment can be made through PayPal at peaceandjusticecenter.com/peacecamp OR a check can be mailed to the Peace and Justice Center 57 N. Franklin St. Wilkes-Barre, PA 18701 and made payable to Peace and Justice Center)

Breakfast and Lunch will be provided for the children.

Scholarships available--please email peacewb@verizon.net and ask!

Email *

Child #1 full name *

Child #1 date of birth *

YYYY

Child #1 current grade *

Child #2 full name

Child #2 date of birth

YYYY

Child #2 current grade

Child #3 full name

Child #3 date of birth

YYYY

Child #3 current grade

Parent or guardian name *

Parent or guardian phone *

Parent or guardian street address *

Parent or guardian city *

Parent or guardian state and zip code *

Emergency contact name *

Emergency contact phone number *

Emergency contact e-mail address *

Emergency contact relation to child(ren) *

Any issues that we should be aware of (allergies, dietary restrictions, diagnosed or suspected conditions, anything that may affect your child's time at camp):

If your child(ren) have specialized dietary restrictions please explain above and plan to send them with a lunch. *

My child will eat the provided lunch.

My child will be sent with a lunch from home.

Permissions *

I hereby consent to the photographing, recording, and/or reproduction of any other manner (including use of video and audiotapes) of the likeness, voice and/or activities of the participant and further authorize the Peace and Justice Center to make unlimited use of promotions, including but not limited to broadcasting of reproductions over the radio, television, and on the Internet (including social networks). I understand that I will not receive any monetary compensation now or in the future of participating. I do hereby release and hold harmless The Peace and Justice Center, its officers, and employees from any claims.

Required

By submitting this document, I acknowledge that I have read it in its entirety, that I understand its contents, meaning, and effect, and that I have agreed to its terms completely and voluntarily. I also acknowledge by submitting this application that I accept the allocation of risks and responsibility as between Peace Camp and myself set forth in this agreement. The Peace and Justice Center is relying on my consent to the terms of this agreement in its operation generally and in allowing my child(ren), in particular, to attend.

A copy of your responses will be emailed to the address you provided.

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