Peace Camp 2018 - Feeding Peace -
La Verne Church of the Brethren
2425 E Street, La Verne, CA 91750
July 23-27, 2018 from 5:30pm - 8:00pm
Students Entering Kindergarten - Entering 6th Grade
$25 Per Camper
Bring a white shirt for your child to tie-dye
Registration Deadline extended to July 15th!
Email address *
Part I: Application
Child's Name (first and last) *
Your answer
Age *
Grade *
Parent name (first and last) *
Your answer
Address *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Emergency Contact name and phone number *
Your answer
Allergies *
Your answer
Parents/Guardians are encouraged to volunteer for a minimum of 2 days in the Global Village (craft center time) from 7:00pm-8:00pm. Please choose a minimum of two days to volunteer. *
Safety Precautions
La Verne Church of the Brethren requires a parent/guardian to stay with children who are disruptive of who refuse to stay with their assigned group.
We may be able to group friends together. If there is a specific friend your child would like in his/her group please list the name here.
Your answer
Part II: Photographic Consent Form
The undersigned does hereby authorize the La Verne Church of the Brethren to photograph/film (type student name): *
Your answer
The undersigned authorizes LVCOB to permit the use and display of said photographs in any publication, multimedia production, display, advertisement or WWW publication. The undersigned releases and forever discharges the LVCOB, its agents, trustees and employees from any and all claims and demands arising out of or in connection with the use of said images, including, but not limited to, any claims for invasion of privacy or defamation.
Accepted and Agreed (please type initials and date) *
Your answer
Electronic signature of parent/guardian *
Your answer
Part III: Parent Permission/Authorization Form
I, the parent/guardian of this applicant give permission for my son/daughter to participate in Peace Camp sponsored by the La Verne Church of the Brethren on July 23-27, 2018. I understand in case of medical emergency, the church staff will make every attempt to contact me and, if necessary, call for medical aid. If I cannot be reached I hereby give my consent to any reasonable medical treatment, (first aid, x-rays, blood tests, anesthetic, or hospital services) rendered under the instructions of hospital staff doctors or emergency personnel.
Printed Name (First and Last) *
Your answer
Electronic Signature and Date *
Your answer
Health Insurance Provider and Policy Number *
Your answer
Doctor's Name and Contact Number *
Your answer
Important Information
Registration is complete once payment has been made. Checks or cash can be delivered to the church office, along with the name of student. 2425 E Street La Verne CA 91750.
Please be on the lookout for upcoming emails regarding Peace Camp 2018.
For further questions - email Amanda at
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