Camp Burt Shurly 2015 Camper Application Fill out the complete form and mail to: Camp Burt Shurly, 15100 Goodband Rd, Gregory, MI 48137.
Phone: (734) 604-2959 / Fax: 517-548-7373. A parent or legal guardian MUST SIGN the application. When your
application is received, a medical form and confirmation letter will be sent to you explaining Camp Burt Shurly
procedures and a suggested list of needed articles for your stay at camp. Camp Burt Shurly will not discriminate
against any individual or group because of race, sex, religion, age, national origin, color, marital status, handicap or
political beliefs.
Camper’s Name: _____________________________________________Home Phone: (____)__________________
Full Address: ___________________________________________________________________________________
Best E-mail Address: _____________________________________________________________________________
Gender: ___________ Age: ________ Birth Date: ______________________Upcoming School Grade:___________
Emergency Contact Name: _________________________________________ Phone: (____)___________________
Will you ride to bus to camp: Yes
No
Cabin Pal (1): __________________________________________
Name of School: __________________________________Name of Teacher________________________________
Please Read and Sign Below: I understand that there will be physical activities of which my child may participate and
that my child maybe exposed to the possibility of injury. I hereby expressly waive any and all liabilities on the part of
Detroit Rescue Mission Ministries (DRMM), Detroit Public Schools (DPS), and their staff for any such injury. I give
permission for routine medical treatment to be administered to my child. In case of an emergency, and I cannot be
contacted, I give permission for DRMM staff to select a licensed physician and authorize the physician to secure
proper treatment for my child. I understand that photos and/or videos may be taken of my child while at camp. I give
permission and consent for my minor child to be photographed and videoed during camp activities. I further give my
permission and consent that any such photographs and videos may be published and used by DPS, DRMM, the
American Camp Association and its agents to illustrate and promote the camp experience through literature, videos,
website or outside advertisement and marketing. All camps are co-ed. When your application is received a medical
form and a confirmation letter will be sent to you explaining camp procedures and a suggested list of needed articles
for your child’s stay at Camp Burt Shurly. If you have additional questions, please call the camp office (734) 604-2959
or visit www.burtshurlycamp.com.
Names of persons other than parent to whom child may be released:
1.______________________________________________2. _____________________________________________
Names of persons to whom child may NOT be released:
1. ______________________________________________2. ____________________________________________
Sign below, then choose your FREE week of camp on the back of this application. Please note you may pick
multiple weeks and whichever pickup location best meets your families needs.
Parent Approval: I approve this application and agree to the terms stated
herein:
Parent or Guardian Signature: _______________________________________
OFFICE USE ONLY
Check Out Signature: __________________________________________________ Camp Burt Shurly offers an exciting residential summer camp experience to Detroit Public School Title One students ages 8 to 12 years of age at NO COST for this campership. Campership includes transportation, activities, lodging & meals. Our Mission is simple – to help kids experience an increase love for learning, expand an affinity for nature, gain a higher level of self-‐esteem, learn to facilitate healthy conflict resolution & create healthy life long goals! Be sure to complete and sign Page 1 of this application. ✔
Bus Stop Pick Up and Drop Off Locations Week of Camp Cost Carver STEM Academy 18701 Paul St, Detroit, MI 48228 July 12-‐July 17 Free Fisher Magnet Upper Academy 15491 Maddelein St, Detroit, MI 48205 July 19-‐July 24 Free Nichols Elementary – Middle School 3000 Burns Street, Detroit, MI 48214 July 26-‐July 31 Free Earhart Elementary – Middle School August 2-‐ August 7 1000 Scotten Ave, Detroit, MI 48209 Free Detroit Children’s Museum August 9-‐ August 14 6134 2nd Ave, Detroit, MI 48202 Free DROP OFF & PICK UP INSTRUCTIONS
· Bus pick up to transport campers to Camp Burt Shurly will be on Sundays at 9:00 AM at the Location identified below per week chosen. We will not start registration before 9:00 AM. A Parent or Legal Guardian must be present and complete the registration process when dropping off a camper. If you arrive at the bus stop after 9:30 AM, your space may be given away. Please be on time! If you have planned to bring your child directly to camp, you should arrive at the camp office at 11:00 AM. · The bus will return campers to the same location on Fridays at 2:00 PM. Please be on time picking up your child! If you are picking up your child from camp, you should arrive at the camp office at 1:00 PM.