Family Therapy Camp Registration 2022
Please fill out this form if you would like to be added to our waitlist for Family Camp!
Name
*
Email
*
This address will receive a confirmation email
Phone
*
Address
*
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AB
AE
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AL
AP
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AS
AZ
BC
CA
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DC
DE
FL
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GA
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HI
IA
ID
IL
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MA
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MD
ME
MH
MI
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MO
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NB
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PA
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QC
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VA
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WA
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YT
Please list the names for any additional adults in your party or N/A
*
Please list the names and AGES of any children in your family or N/A:
*
Need any special accommodations?
Do you wish to contribute additional funds to go towards our general scholarship fund or towards covering the registration for a specific family?
*
Please select one option.
General Scholarship Funds
Specific Family
I do not wish to donate funds at this time
Select Option
General Scholarship Funds
Specific Family
I do not wish to donate funds at this time
Amount/special instructions for additional funds being donated or N/A:
*
Will you need financial assistance to attend camp?
*
Please select one option.
Yes
No
Select Option
Yes
No
Please list the dollar amount of financial assistance you are needing or N/A. Amounts awarded will be based off of need, and scholarship funds available:
*
You will be invoiced for the total amount you owe (minus financial aid amounts awarded if applicable). All outstanding balances must be received by August 1st or your family will be moved to the wait list. Please indicate whether you would like to receive your invoice by email or physical mail:
*
Please select one option.
Email Invoice
Mail Invoice
Select Option
Email Invoice
Mail Invoice
Would you like to receive emails or texts about current and upcoming classes offered through Good Samaritan Ministries?
*
Please select one option.
Text
Email
No Updates
Please double check that your contact information is accurate. Invoices will be emailed/mailed once your registration is submitted based off the preferred contact method you have listed above.
Submit
Description
Please fill out this form if you would like to be added to our waitlist for Family Camp!
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