2016 CAMP STELLA MARIS SUMMER REGISTRATION FORM

 2016 CAMP STELLA MARIS SUMMER REGISTRATION FORM 
1) Parent/Guardian Contact Information:
Marital status:
Parent/Guardian 1 : ___________________________________
Parent/Guardian 2: ______________________________________
Mailing Address: _____________________________________
Mailing Address: _______________________________________
City: ______________________________________________
City: _________________________________________________
State: ______________
State: ______________
Zip: __________________________
Zip: ____________________________
Cell Phone: ________________________________________
Cell Phone: ___________________________________________
Home Phone: _____________________________________
Home Phone: _________________________________________
E-Mail Address: ______________________________________
E-Mail Address: ________________________________________
Employer/position: ____________________________________
Employer/position: ______________________________________
*Parent/Guardian 2 will also have access to camper registration and
health information if a name is listed above.
□ Married □ Divorced
□ Separated □ Widowed
□ Single Mother □ Single Father
Camper lives with:
□ Both
□ Joint
□ Mother □ Father
□ Other: _________________
Confirmation will be sent
via e-mail.
*Please make sure we have
your correct e-mail address*
2) Camper Registration: (Please list all campers below)
Program
Code
Camper Name
Birthday
MM/DD/YY
M/F
Current
Grade
Dietary Concerns
Has your camper
received his or her
First Holy
Communion?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Cabin Mate
Request
*see below*
Total $
*Cabin Mate Request: Each camper may choose to request ONLY ONE cabin mate. To consider the request, BOTH campers must request each other. If more
than one camper name is listed, we will pick one camper from your list. Campers are assigned to cabins by age, not grade. There are no guarantees.
Where did you hear about us? _________________________________________ Who referred you to CSM? ___________________________________________
3) Camper Programs:
4) Payment:
OVERNIGHT EXPERIENCE (Ages 6-11)
RESIDENT CAMP (Ages 7-15)
Must be 15 or younger during session.
Program Code:
Dates:
Program Code:
Dates:
Price:
OE A
June 26-28
$325
August 14-16
$325
Res A
June 26-July 2
$620
OE H
Res B
July 3-8
$590
*Please see handbook for pick-up and drop-off times.
Res C
July 10-16
$620
Res D
July 17-22
$590
LEADERS-IN-TRAINING PROGRAM (Age 15)
Res E
July 24-30
$620
**Please number sessions, 1-4, in order of preference.**
Res F
July 31-Aug 5
$590
Res G
August 7-13
$620
Res H
August 14-19
$590
Program Code:
_____ LIT 1:
Dates:
4DAY A
June 26-29
$400
4DAY B
July 3-6
$400
4DAY F
July 31-Aug 3
$400
_____ LIT 4:
G/H Weeks
$235
S
$_____________
*Sibling Discount
$(_____________)
*Deduct $20 for each additional child
registered (after one) per household per session.
TOTAL:
Program Code:
Dates:
A/B Weeks
Day 3
July 11-15
$235
S
Day 4
July 18-22
$235
F
Day 5
July 25-29
$235
S
$235
B/C Weeks
$1190
Camp Registration Agreement:
 I agree to be responsible for all fees and payment terms selected.
 I have read and agree to all terms included on this registration and
conditions relating to programming, fees, and refund policies.
______________________________________________________
Signature of parent/guardian
Date
Payment Agreement:
Price:
$840
Please select method of deposit and
one balance payment option.
*Deposit due upon registration: Non-refundable $75 per camper
per session (deposit will be applied to registration fee)
 Payment Option 1: Payment in full today:
 Credit/Debit card
 Check # ___________________
F
Day 7
August 8-12
$235
S
Day 8
August 15-19
$235
F
Day 9
August 22-26
$210
For early drop off:
7:30-8:45 am
$25/wk
Add EDO next to program code (i.e. Day 4 EDO)
= Optional sleep-over is scheduled this week.
= Fieldtrip is scheduled this week.
 For a list of fieldtrips offered and sleep-over information
please go to www.campstellamaris.org.
$840
July 3-8 & July 10-16
_____ CIT 3:
C/D Weeks
_____ CIT 4:
$840
 Credit/Debit card*
D/E Weeks
 Check # ___________________
E/F Weeks
$840
$840
July 24-30 1 & July 31-Aug 5
_____ CIT 6:
F/G Weeks
G/H Weeks
*Selecting Payment Option 2 and using a credit/debit card, CSM
will debit your account automatically on April 1st.
 MasterCard
 Visa
 American Express
 Discover
$840
July 31-Aug 5 & Aug 7-13
_____ CIT 7:
 Payment Option 2: Payment in full April 1, 2016
July 10-16 & July 17-22
July 17-22 & July 24-30
_____ CIT 5:
$_____________
$1190
**Please number sessions, 1-7, in order of preference**
F
$235
F
Contribution to CSM Campership Fund:
COUNSELOR-IN-TRAINING PROGRAM (Age 16)
_____ CIT 2:
Price:
July 4-8
S
$_____________
June 26-July 2 & July 3-8
Day 2
August 1-5
Total Fee (include all campers from above):
Aug 7-13 & Aug 14-19
DAY CAMP (Ages 5-12)
Day 6
$1190
July 24-30 & July 31-Aug 5
_____ CIT 1:
June 27-July 1
$1190
E/F Weeks
Price:
*Campers will have the opportunity to extend their stay for
the remainder of the week after communication between
the parent/guardian & counselor - an additional rate would
apply.
Day 1
A/B Weeks
C/D Weeks
_____ LIT 3:
Program Code:
Dates:
Price:
July 10-16 & July 17-22
4 DAY STAY (Ages 7-15)
Program Code:
Dates:
June 26-July 2 & July 3-8
_____ LIT 2:
Calculate Balance:
Price:
Card #:________________________________ Exp. Date:________
$840
Aug 7-13 & Aug 14-19
Name on Card: __________________________________________
Registration Questions:
Signature: ______________________________________________
Call: (585) 346-2243, ext. 104
Email: [email protected]
Refund/Cancellation Policy:
Mail to:
Camp Stella Maris
4395 East Lake Road
Livonia, NY 14487
Fax to: (585) 346-6921
Scan to: [email protected]
www.campstellamaris.org
 FULL payment must be postmarked by June 1, 2016 to avoid
cancellation.
 Cancellation made prior to June 1, 2016, a full refund, less the
deposit, will be issued.
 Cancellation made after June 1, 2016, no refund will be given.