Please enable JavaScript in your browser to complete this form.Camper's InformationCamper's Name *SEX *MaleFemaleCampers must select their birth sex here. Please visit our statement of faith or FAQ page for clarification on CBX's stance on gender/sex. Street Address (for mail) *Street Address line 2City *State *Zip / Postal *Camper's PhoneCamper's EmailCamper's Birthday *Camper's age at the day camp starts *Grade next fall *To whom do you want the camp info sent? *FatherMotherSomeone elseIf someone else, please enter their name and address.Father's InformationIf the camper's father is not a part their life, the mother's information is required.Father / Guardian NamePersonal Phone (Cell / Home)If you have a cell phone, that is preferred in case of emergency.Address if differentEmploymentEmployment PhoneEmployment AddressMother's InformationIf the camper's mother is not a part of their life, the father's information is required.Mother / Guardian NameAddress if differentPerson Phone (Cell / Home)If you have a cell phone, that is preferred in case of emergency.EmploymentEmployment PhoneEmployment AddressAdditional Emergency ContactIn case of early or emergency dismissal for health or behavioral reasons, the following person is authorized by the parent/guardian to receive the camper if parent/guardian cannot:Full Name *Relationship to Camper *The following person(s) are authorized to pick up my child If it is only you, just list yourself (please include address and phone):Name(s), Address(es), Phone(s) *Household InformationCamper is living with *Both parentsFatherMotherFoster homeOtherIf other, please describeFamily demographicsCaucasianHispanicAfrican AmericanAsianNative AmericanOtherCheck all that applyIf other, please describeCamper's parents are *MarriedSeparatedDivorcedOne or both deceased2025 Camp ChoicesPlease select one *Boys Falcon | 9-11 year olds | June 2 - 7thGirls Falcon | 9-11 year olds | June 9 - 14thBoys Eagle | 12-14 year olds | June 16 -21stGirls Eagle | 12-14 year olds | June 23 - 28thBoys Red Hawk | 14-17 year olds | June 30 - July 5thGirls Red Hawk | 14-17 year olds | July 7-12thPayment for camp *Full cost ($300)Subsidized Cost ($100, must meet income qualification requirements)I will contact CBX about a scholarshipMy camper is a foster childMy camper is with Project Angel TreeFirst time camper with CBX? *YesNoIf no, how many years has the camper attended CBX?T-Shirt Size *Youth MediumYouth LargeAdult MediumAdult LargeAdult X-LargeAdult XX-LargeInsurance / Health Share InformationIf none, write "NONE" or "NA". All registrants are covered by excess camper medical insurance and subject to the limits thereof. Individual insurance is primary.Insurance CompanyPolicy NumberInsurance PhoneInsurance AddressDoctor's NameClinic / HospitalDoctor's PhoneDoctor's AddressParent / Guardian SurveyWe want to determine the best way to work with your family and your child during camp and afterwards. We are thankful for any input you may be able to provide. This survey is seen only by the camp directors and your child’s camp counselor. It helps us to know what our campers need in the form of encouragement, lesson topics, and possible follow-up ministry. Thank you for your time.Your Full NameIn the space provided below, tell us how you would like to see your son/daughter grow:What do you see as the biggest challenge your child is facing right now?Do you attend church?YesNoIf yes, how often?Each weekSometimesSeldomIf yes, where?How would you like to see us contact/visit your child during the rest of the year?Fall & Winter retreatsHome visitsPhone callsCards / lettersEmailsAt ChurchOne-on-one mentoringSmall group / Bible studyOthercheck all that applyIf other, please describeHow did you hear about Cross Bar X? (include individual's or organization's name)Your statusMarried parentSingle parentGuardianOtherIf other, please describeHow can we pray for you and your family?Is there anything else we should know about your camper?Follow Up SectionAt Cross Bar X, we want to be more than just a summer camp experience, but a continued experience in your area too. We believe in continuing our time with campers through our follow up program. Angele and Scar have been spending time with many of our campers throughout the year after school doing any and every activity that campers enjoy, whether that be the rec center, eating ice cream, attending sports activites, having dinner, and more. They care about you and want to spend time with you throughout the year. If you want to be included in follow up, please fill out the following information.Camper NameCamper EmailCamper PhoneGuardian NameGuardian EmailGuardian PhoneBest time to contact/ best times available:Does the camper play in any sports?Things the camper likes to do:Upload FormsYou may optionally print, scan, complete, and upload the additional forms listed below. If you do not upload them with this application, you are required to physically mail them with your $50 deposit. Summer Camp Release & Waiver Physical, Health Record, And Certificate of Immunization Income Eligibility (Optional - only required if applying for low-income camp pricing) Summer Camp Release & Waiver Click or drag a file to this area to upload. Physical, Health Record, And Certificate of Immunization Click or drag a file to this area to upload. Income Eligibility Click or drag a file to this area to upload. Extra Form(s) 1 Click or drag a file to this area to upload. Use this in case your files got separated and you need an additional upload field.Extra Form(s) 2 Click or drag a file to this area to upload. Use this in case your files got separated and you need an additional upload field.PhoneSend Application
