Registration & Permission Form
for Camp Peaceful Pines, Inc. - Return to main page
Costs and Camp Descriptions Link
Print one form for each camper, then fill out by hand and mail with your check.
Note: If you email the registrar with your intent to attend, your payment must follow within 10-15 days to be considered "registered."
Registration mail: Peggy Castañeda, 1704 Thorsen Ave, Modesto CA 95355-1830
last update 3/19/2008

Camper's last name:	First Name:	Gender:
Camper's Birth Date/Year:	Age:	School Grade just completed:
Camper's mailing address:
City/State/Zip+4
Phone Day:  (         )	Phone Eve:  (         )	Email:
Camper's Local Church:
Parent/Guardian's Name:		Email:
Address if different from above:
City/State/Zip+4
Parent/Guardian's Phones: (         )	Parent/Guardian's Phones: (         )
Emergency Contact Name:
Emergency Contact Phone numbers:
.Need for Accessible cabin yes, no	.Desire Vegetarian Food yes, no
Check camp you will be attending:   2008 Dates: Due by: Description: Amount Sent: May 23-26 phone Kickoff Work Camp Donations are welcome June 20-27 June 1 June Family Camp #1 $ June 29-Jul 4 June 1 WRYC Youth Camp: Completed grades 9 to 14 $ July 19-25 July 1 Discovery Camp (unstructured family & hiking) $ July 25-Aug 1 July 1 July Family Camp #2 $ Aug 2-8 July 1 Junior Camp: Completed 4th, 5th or 6th grades $ Aug 2-8 July 1 Jr. High Camp: Completed 6th, 7th or 8th grades $ Aug 29-Sep 1 Aug. 15 Labor Day Weekend Camp Donations are welcome $20 after "Due Date" Fee if applicable: $ Family Camps $50 extra if you do not preregister before you get to camp. $ Check # _______ Total fee enclosed: $ If your registration is postmarked after the due date, add $20 to the cost of your camp. Refunds: If you are unable to attend camp after you have registered, all but $10.00 of your registration will be refunded if your cancellation is received two weeks prior to a specific camp; otherwise, no refunds. Family Camps: If you do not preregister before you get to camp, there will be a $50. fee above and beyond the late registration fee. This fee is not designed to punish campers, but to encourage timely registration to help the cooks and leaders as they plan for everyone at Camp.  . T-shirt size for Junior, Junior High, Youth Camp: Indicate shirt size here: small, medium, large Dress Code: Appropriate dress has become an issue at some camps. Please be advised that all campers are expected to dress in suitable and modest attire while attending camp. A complete dress code will be sent to campers before their scheculed camp. The Camp Directors and Counselors have the authority to monitor campers for compliance with the dress code. Pledge for Junior, Junior High and Youth campers: "In signing this registration form I agree to abide by all camp policies and use f camp property. I agree to cooperate and participate in all camp activities." Camper's Pledge Signature: Date: "As parent/guardian, I give permission for person named to be photographed and/or videotaped for promotional purposes." Parent/Guardian Photo Signature: Date: Send your registration to, or contact with questions:      Camp Peaceful Pines, Registrar Peggy Castañeda, 1704 Thorsen Ave, Modesto CA 95355-1830   campPPregister@gmail.com      Fax: 209-578-0670   Voice: 209-521-1525 Short of Funds? The Camp Board believes that EVERYONE should be able to come to camp regardless of financial ability. Many churches and individuals are ready and willing to help you financially. Ask them. .....In addition, the camp has scholarship funds available. Requests for camp funds must come through your local church. Contact the retistrar, Peggy Castañeda, for further information.
Health History for Junior, Junior High and Youth Campers: . List any allergies including food allergies or other intolerance:   . List any other health needs or medical conditions:   . If you are allergic to bee stings, you must bring a sting kit with you to camp and give it to the Camp Director. . If the camper is on any medication and brings his/her medication to camp, please list dosage, frequency, purpose, and turn it over to the Camp Director.  Check all that apply:   Frequent colds   Frequent sore throat   Bedwetting   Stomach upsets   Heart trouble   Epilepsy   Sleep walking   Diabetes   Asthma .I give permission for my child to be treated by a physician or in a hospital in case of an emergency.  Signature of parent/guardian:  Date:  Your health insurance carrier:  Policy or Group #:  Emergency Phone numbers:  Please list or attach immunization records:

Keep a copy of this sheet for your records. // Your check will be your receipt.