PeaceMaker Kids Registration Form

Please fill out this form and click submit.

Child's Name

*

Child's Address

*

Child's Date of Birth

*

Child's School Grade

*

Please select one option.

K 1 2 3 4

Caretaker's Name

*

Caretaker's Phone

*

Caretaker's Email

*

This address will receive a confirmation email

2nd Caretaker's Name

*

2nd Caretaker's Phone

*

2nd Caretaker's Email

*

This address will receive a confirmation email

Emergency Contact Name

*

Emergency Contact Phone

*

Allergies/Medical Information

*

Is there additional information that would be helpful for us to know about your child, particularly any learning, developmental, or behavioral needs?

*

Do volunteers at the PeaceMaker Kids Camp have permission to provide any necessary first aide or take your child to emergency care if needed?

*

Please select one option.

yes no

Who will be picking your child up from camp each day?

*

As the Caregiver, I give permission to PeaceMaker Kids Camp and Community Church of Durham, to use photos or video of my child in related publications, press releases, or social media sites (children's last names are NOT included).

*

Please select one option.

yes no

Select Camp Sessions

*

Please select all that apply.

Monday 9:00am - 12:00pm Monday 1:00pm - 4:00pm Tuesday 9:00am - 12:00pm Tuesday 1:00pm - 4:00pm Wednesday 9:00am - 12:00pm Wednesday 1:00pm - 4:00pm Thursday 9:00am - 12:00pm Thursday 1:00pm - 4:00pm Friday 9:00am - 12:00pm Friday 1:00pm - 4:00pm

How did you hear about this camp?

*

Each Camp Session is $20

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Please fill out this form and click submit.

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