Peace Camp Rocks! 2018
July 9-13, 2018 from 4:45-8:00pm
Children Preschool - Entering 6th Grade

Claremont United Methodist Church
211 W. Foothill Blvd.
Claremont, CA 91711
Contact us at (909) 624-9021 or

Part 1: Application
Child's Name (first and last) *
Your answer
Age *
Grade (entering) *
Parent/Guardian Name (first and last) *
Your answer
Address *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Emergency Contact (name & phone number) *
Your answer
Allergies *
Your answer
Parent/Guardians are encouraged to volunteer in our program for at least 1 evening during the week. Please indicate below which evenings you are available to help. *
Part 2: Photographic Consent Form
The undersigned authorizes Claremont UMC to photograph/film (type student's name) *
Your answer
Electronic Signature of Parent/Guardian and Date *
The undersigned authorizes Claremont UMC to use and display said photographs in any publication, multimedia production, display or advertisement. No child will be identified or named in conjunction with their photo or video presentation.
Your answer
Part 3: Parent Consent/Authorization Form
I, the parent/guardian of this applicant give my permission for my son/daughter to participate in Claremont United Methodist Church's Peace Camp Rocks. I understand that in case of medical emergency the church staff will make every attempt to contact me and, if necessary, call for medical assistance. If I cannot be reached, I give my consent for Claremont United Methodist Church or its representative to authorize emergency medical treatment for my minor child during the week of July 9-13.
Printed Name (first and last) *
Your answer
Electronic Signature and Date *
Your answer
Health Insurance Provider & Policy Number *
Your answer
Doctor's Name & Contact Number *
Your answer
Important Information
We are so happy that you will join us for this fun week! Registration is complete once payment has been made. Checks or cash, with the student's name included, can be delivered to the church at 211 West Foothill Blvd, Claremont, CA 91711. For further questions, please contact Sara Swift Tharpe at
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