Cost: $125.00
Girls’ Camp July 13-17; deadline: July 2
Boys’ Camp July 20-24; deadline: July 11
2015 CAMP ANDREWS APPLICATION
We have a limited amount of space so sign up early in order to confirm a spot
Due to our Youth Center being in Honey Brook, we prioritize local youth
Ages 9-15
Name: ___________________________________________________________________Age: _________
Birth Date: __________________Sex: M/F (circle one) T-shirt size: Adult sizes S, M, L, XL Youth: S, M, L
Parent/Guardian Name: _______________________________________
Phone no: ________________________ Additional emergency contact no._________________________
Email:________________________________________________________
Mailing Address: _______________________________________________
City: ________________________________________ State: _________________ Zip: _______________
Allergies:________________________________ Physical Restrictions:_____________________________
Medications: ____________________________________________________________________________
Medical Insurance Carrier:___________________________ Policy no._____________________________
CAMPERS, please complete the following section:
Favorite activities: ___________________ ____________________ _____________________
What is one question that you would like to have answered or discussed at camp? __________________
_____________________________________________________________________________________
Packing List:
Bible
Sleeping bag & pillow
Towels & washcloths
Closed toe shoes & water shoes
(2 pairs of shoes since 1 pair will get wet)
 Jacket or sweater
 Swimsuit
 Several changes of clothing
 Flashlight
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


Please bring only luggage that you can carry
Parents; please have campers leave these
items at home:
 Any electronic device (tablets & smart phones)
 Valuable personal items
 Bikini
 Tank tops for girls
 Snacks
 Cash
Although great care will be taken by camp directors to protect personal items, Camp Andrews and
Honey Brook Community Church cannot be responsible for lost or damaged items.
Payment:
The total cost of camp for your child is $125.00. Honey Brook Commu- For office use only:
nity Church offers assistance if you are unable to pay the full amount.
Paid ___ Not Paid ____
However, applications will not be accepted without the $50.minimum.
Amount paid ________
___ $125.00 ___$80.00 ___$50.00
Date of payment __________
Make checks payable to Honey Brook Community Church.
Method of payment:
Please send your registration to the following address:
Honey Brook Youth Center
___ Cash ___Check
PO Box 28
Check #________
Honey Brook, Pa 19344
Please arrive at Honey Brook Elementary School along Walnut Street by 8:00 a.m. on Monday.
You can pick up your child on Friday at 4:30 p.m. at the Honey Brook Elementary school.
Questions? Merv & Juanita Petersheim 717-808-9240 (Boys’ Camp)
Jake & Becky Esh: 610-273-3085 (Girls’ Camp)
Honey Brook Youth Center 610-273-1073
PARENT AUTHORIZATION, COVENANT, RELEASE & INDEMNITY AGREEMENT
_________________________________ Childs name, printed
_________________________________ Parent/Guardian (printed)
_________________________________ Parent/Guardian (both names of Parents/Guardians are required, when applicable)
Camp Andrews, its agents, employees, affiliates, successors, and Honey Brook Community Church are hereinafter collectively referred to as "Provider.”
In the event that I cannot be reached in an emergency, I give my permission to the physician selected by Provider to
hospitalize and secure proper treatment as necessary for my child named above.
In consideration of permission granted my child to participate in camping and related activities, which I acknowledge
are inherently dangerous, I hereby accept unto myself all responsibility and all liability for any injury, death or other
claim, loss or damage, caused by, or arising out of camping and other related activities sponsored by Provider. I
hereby release and covenant with Provider that I will never, individually or as legal guardian of my child, institute any
action for any injury, death or other claim, loss or damage, caused by, or arising out of camping and other related
activities sponsored by Provider. I further agree to indemnify and hold Provider harmless against any and all claims,
demands, actions, and causes of action (including actual attorneys’ fees, costs and expenses) of my child or my child’s
legal guardian that may arise as a result of my child's participation in camping and other related activities sponsored
by Provider.
I hereby give my permission for any photography of my child on camp premises to be used in publicity for Provider.
Intending to be legally bound,
Signature of Parent/Guardian: ____________________________Date: ____________ Birthdate:____________
Signature of Parent/Guardian: ___________________________ Date: _____________ Birthdate:____________
****both signatures of Parents/Guardians required when applicable*****