CAMP & RETREAT CENTER
226 Camp Rockfish Rd., Parkton NC 28371
PLEASE PRINT CLEARLY OR TYPE: (Separate Applications Required)
Camper Name: ________________________________________________________
Phone: (_____) ____________ Age: _____________ Birthday: ___/___/____________
Full Address (Including Zip Code) __________________________________________
______________________________________________ Zip __________________
Parent/Guardian Name and Address:_________________________________________
______________________________________________________Zip ____________
Please share any information which would help us better understand this camper:
___________________________________ __________________________ __________
____________________________________ ______________________ _____________
Please select the week(s) you wish to attend:
___June 16-20 ___June 23-27 ____ June 30- July 4 ___July 7-11 ___July 14-18
Registration is required. Limited space is available so register Early!
This program is for children who are completing Kindergarten- the fifth grade.
Deposit: A $65.00 non-refundable non-transferable deposit per week per child is expected with registration form. The deposit(s) will be deducted weekly from the total week fee. The balance ($50.00) of which is due the first day of camp.
An optional HOT LUNCH can be provided each day for $25.00/week. Please indicate, with your initials, if you would like your child to receive a HOT LUNCH _____ YES.
An optional OVERNIGHT STAY on Thursday night can be arranged for $20.00/child. Please indicate, with you initials, if you would like your child to stay overnight.
OVERNIGHT STAY: ______ Yes
Optional SWIMMING LESSONS can be provided for $50.00/child. Please indicate, with your initials, if you would like your child to received swimming lessons.
SWIMMING LESSONS: ______ Yes
Check #___________________Amount of Payment $______
A $25.00 FEE WILL BE CHARGED ON ALL RETURNED CHECKS
Total number of weeks you wish to register for: ______
Total Cost: ($115.00 per week) $_______
Total amount of deposit: ($65.00 per week) $______
Balance due: $______
Please complete this form and return it with the required deposit, check/money order payable to Camp Rockfish send to: 226 Camp Rockfish Rd., Parkton NC 28371, for credit card payments call (910) 425-3529 . Please write the camper's name on the check and do not staple check to application. All applications must be accompanied by the appropriate deposit- No exceptions. All other forms should be completed and brought with your child the first day of camp. Please call if you have any questions. (910) 425-3529
Parents, please Check which applies to your child:
__I prefer that photographs, videos and other facsimiles of my child not be used in promotional or souvenir
materials for camp.
__I do not mind if photographs, videos and other facsimiles of my child are used in promotional or souvenir
materials for camp.