2018 Peace Camper Registration Form
Peace Camp For Kids 2018: "Developing the Character Traits of Peacemakers"

When: Monday, July 30th to Friday, August 3rd, 9 a.m. to 3 p.m.

Where: First Presbyterian Church, 97 South Franklin Street, Wilkes-Barre (next to Osterhout Library, and across from YMCA)

Who: Children entering first grade through eighth grade in September 2018 are eligible for Peace Camp 2018

Fees:
One child $75
Two children $150
Family rate (three children and more) $200
Scholarships Available; please call (570) 823-9977 and ask


The official registration and financial information of the Interfaith Resource Center for Peace and Justice may be obtained from the Pennsylvania Department of State by calling toll-free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement.

Email address *
Child #1 full name *
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Child #1 date of birth *
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Child #1 most recent grade completed *
Child #1 Allergies (Including Medical Reaction), Special Disabilities (If Any), Medication Needs, Any Special Conditions, Dietary Needs, Any Special Needs:
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Child #2 full name
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Child #2 date of birth
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Child #2 most recent grade completed
Child #2 Allergies (Including Medical Reaction), Special Disabilities (If Any), Medication Needs, Any Special Conditions, Dietary Needs, Any Special Needs:
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Child #3 full name
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Child #3 date of birth
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Child #3 most recent grade completed
Child #3 Allergies (Including Medical Reaction), Special Disabilities (If Any), Medication Needs, Any Special Conditions, Dietary Needs, Any Special Needs:
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Parent or guardian name *
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Parent or guardian phone *
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Parent or guardian home address *
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Parent or guardian e-mail address *
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Emergency contact name *
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Emergency contact phone number *
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Emergency contact e-mail address *
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Emergency contact relation to child(ren) *
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Any issues that we should be aware of: (Use another sheet of paper if needed)
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PARENT/GUARDIAN(S) CONSENT: Please check each item listed below to acknowledge consent: *
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