Registration for Chalice Camp 2025

Your Email

This address will receive a confirmation email

Child's Info

Name of Child

Child's Pronouns

Name of Home Congregation

Grade Entering Fall 2025

1st Grade 2nd Grade 3rd Grade 4rd Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade

Applying to be a CIT?

Yes No

Child's T-shirt size

Child's XS Child's S Child's M Child's L Adult S Adult M Adult L Adult XL

Guardian Info

Guardian #1 Name

Guardian #1 Pronouns

Guardian #1 Phone

Guardian #1 Email

Guardian #1 Address

Guardian #2 Name

Guardian #2 Pronouns

Guardian #2 Phone

Guardian #2 Email

Guardian #2 Address

Emergency Contact Info

Emergency Contact #1 Name

Relationship to child

Emergency Contact #1 Phone

Emergency Contact #1 Alternate Phone

Emergency Contact #2 Name

Relationship to child

Emergency Contact #2 Phone

Emergency Contact #2 Alternate Phone

Medical Information

Physician's Name

Physician Phone Number

Physician Address

Health Insurance Provider

Policy Number

Health Insurance Phone Number

Are there any restrictions to your child’s participation in a complete camp activity program? (If yes, please specify)

Are there any emotional or behavioral needs of which we should be aware of? (If yes, please specify)

Does your child utilize medication that the directors need to know about (i.e. epipen, attention medication, insulin, etc.)? (If yes, please list medication, purpose and how to administer)

Does your child have any other illness, disability or chronic condition of which we should be aware? (If yes, please specify)

Does your child have any allergies to food or medications? (If yes, please list)

Pick up list

Please write all possible adults that might pick up your child

Guardian Authorizations and Permissions

By signing below you agree to: • In case of medical emergency, I hereby give permission to the Camp Directors to secure proper medical treatment for my child. In emergency cases, it is camp policy to make every reasonable effort to contact the parent/guardian immediately. • Be responsible for all medical, hospital or other expenses not covered by my insurance carrier which may incur as the result of securing treatment. • I assume responsibility for any liability which may arise for damages, loss or injuries which may be caused or contributed to by my child to the person or property of others. • I understand the medical information must be completed. • I understand that Chalice Camp is not responsible for my child’s personal property. • I give permission to use still, slide, or video photographs of my child for public relations. • I give permission for my child’s phone number and address to be used in a camper group list to be given to other campers. • I have read and accept the policies and fees printed on the Chalice Camp application and registration forms. I represent that the statements I make herein are true and accurate. Please type your full name

Additional Info

Is there anything else we need to know to help your child be successful at Chalice Camp?

Payment

Please enter the price for camp ($400 for camper; $200 for CIT) in the box.

Do you need to apply for financial aid?

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Registration for Chalice Camp 2025

Description

Please Fix the Following