Please enable JavaScript in your browser to complete this form.Parents or Guardians Name *FirstLastEmail *EmailConfirm EmailParents or GuardiansPhone *Parents or GuardiansCamper Name *FirstLastDOB *Sex *Choose OneFemaleMaleAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMy child will attend Winter retreat *Youth Retreat 1- Ages 8-13 -January 24-26 - $75.00Youth Retreat 2- Ages 8-13 -February 21-23 - $75.00Teen Retreat- Ages 13-17- February 7-9 - $75.00Two Retreats - $140.00All Three retreats - $200.00CheckboxesYouth Retreat 1Youth Retreat 2Teen Retreat . Adult / Youth . I would like to purchase a sweatshirtCBC Sweatshirt Adult - $35.00CBC Sweatshirt Child - $35.00Adult Sizes *Adult MediumAdult LargeAdult X-LargeAdult XX-LargeChild Sizes *Youth SmallYouth MediumYouth LargeTotal$0.00My Child Works with the following Specialized Plan(s) *Treatment PlanBehavioral PlanCare PlanDietary Plan (Food Allergies, Sensitivities, Vegan or VegetarianMy Child Does not work with a specialized plan(s)We want your child succeed and have a great weekend at camp. This information will help us make them have a successful weekend. Explain *Please explain the specialized Plan(s) your child works with. If your Child has a food allergy please explain the severity of the allergy. Before Clicking submit please print or save the health form for your child provided, in the link below. The health form can emailed or faxed two weeks prior to your arrival at camp. WintercampHealthform Payment *CardName on CardSubmit