All questions with a red asterisk are required.

Please CLICK HERE to read and approve the Koinonia Nature Camp Policies and Payment Options.
   I have read and agree to the camp policies and payment options. *

Parent First Name: *
Parent Last Name: *
Parent Mobile Phone: *
Parent Work Phone:
Parent Employer:
Parent Email: *
Parent Street Address: *
Parent City: *
Parent State: *–Please select–AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutD.C.DelawareFloridaMicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriMarianasMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyomingMilitary AmericasMilitary Europe/ME/CanadaMilitary Pacific
Parent Zip: *

Parent 2 First Name:
Parent 2 Last Name:
Parent 2 Mobile Phone:
Parent 2 Work Phone:
Parent 2 Employer:
Parent 2 Email:
Parent 2 Street Address:
Parent 2 City:
Parent 2 State:–Please select–AlaskaAlabamaArkansasAmerican SamoaArizonaCaliforniaColoradoConnecticutD.C.DelawareFloridaMicronesiaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMarshall IslandsMichiganMinnesotaMissouriMarianasMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoPalauRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsVermontWashingtonWisconsinWest VirginiaWyomingMilitary AmericasMilitary Europe/ME/CanadaMilitary Pacific
Parent 2 Zip:

Which parent/guardian should receive emails/phone calls/texts?*–Please select–Send communications to both contacts listedSend communications only to the first contact listed

First Child’s Full Name *
First Child’s Date of Birth: *
First Child’s Grade Completed: *–Please select–Kindergarten1st2nd3rd4th5th6thYoung Leader Program (age 12-15)
First Child’s Gender: *–Please select–MaleFemaleNon-BinaryPrefer not to say
First Child’s Ethnicity: *–Please select–African-American/BlackAfrican National/African CaribbeanAmerican-Indian/Alaskan NativeArab/Middle EasternAsian/Pacific IslandernLatino/HispanicWhiteMulti-racialPrefer not to say

Second Child’s Full Name:
Second Child’s Date of Birth:
Second Child’s Grade Completed: –Please select–Kindergarten1st2nd3rd4th5th6thYoung Leader Program (age 12-15)
Second Child’s Gender: –Please select–MaleFemaleNon-BinaryPrefer not to say
Second Child’s Ethnicity: –Please select–African-American/BlackAfrican National/African CaribbeanAmerican-Indian/Alaskan NativeArab/Middle EasternAsian/Pacific IslandernLatino/HispanicWhiteMulti-racialPrefer not to say

Third Child’s Full Name:
Third Child’s Date of Birth:
Third Child’s Grade Completed: –Please select–Kindergarten1st2nd3rd4th5th6thYoung Leader Program (age 12-15)
Third Child’s Gender: –Please select–MaleFemaleNon-BinaryPrefer not to say
Third Child’s Ethnicity: –Please select–African-American/BlackAfrican National/African CaribbeanAmerican-Indian/Alaskan NativeArab/Middle EasternAsian/Pacific IslandernLatino/HispanicWhiteMulti-racialPrefer not to say

The following are names of people other than the parents/guardians listed above who can be contacted IN CASE OF AN EMERGENCY, and/or may PICK UP YOUR ILL CHILD if you cannot be reached. You must list someone in addition to yourself or your spouse. If there are any specifications about custodial rights or pick-up rights, they must be submitted IN WRITING to Koinonia.

Emergency Contact 1 Name: *
Emergency Contact 1 Phone: *
Emergency Contact 1 Relationship: *–Please select–GrandparentOther Family MemberFriendOther
Emergency Contact 2 Name:
Emergency Contact 2 Phone:
Emergency Contact 2 Relationship: –Please select–GrandparentOther Family MemberFriendOther
Are there custody/safety concerns that Koinonia should be aware of?*–Please select–NoYes

Name of Child’s Physician: *
Physician Phone: *
Medical Insurance Company:
Insurance Policy Number:
Name of Child’s Dentist:
Dentist Phone:

Please indicate which session(s) you are registering for. If a week is filled, we will add your name to our waiting list and will let you know if you have a spot. If no spot becomes available, your $25 deposit will be refunded or put toward the tuition of another session.

Please CLICK HERE to review prices and payment options.

Session 1 – July 1-3
No ToH scholarships available for this week – Childcare council vouchers will be accepted
Non-Resident Standard Day
Non-Resident Extended Day
Not attending this week

Session 2 – July 8-12
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 3 – July 15-19
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 4 – July 22-26
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 5 – July 29-Aug 2
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 6 – Aug 5-9
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 7 – Aug 12-16
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 8 – Aug 19-23
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

Session 9 – Aug 26-30
Non-Resident Standard Day
Non-Resident Extended Day
ToH Resident Standard Day
ToH Resident Extended Day
Not attending this week

How will you be submitting payment?*–Please select–I will be making a single payment in fullI will be paying weekly
Will you be applying for financial assistance, either through the Sullivan County Child Care Council or through Koinonia directly?*–Please select–Yes I will be applying for assistanceNo I will NOT be applying for assistance