All fields marked with red “*” are required. In case you will miss any required field the form will not get submitted and will show error(s) on those missed fields. Make sure you have filled the form correctly before submitting.

Camper Information

Parent/Guardian Information 1
Parent/Guardian Information 2
Health Insurance Information
Please check any session you would like to attend.*
SessionWeeksTuitionSelectExtension **
Session 1
Jun 07 to Jun 21
Session 2
Jun 21 to Jul 05
Session 3
Jul 05 to Jul 19
Medical Deposit * Medical deposit is fully refundable, less any portion used. Refund checks are issued by the end of October, after camp.
Cognitive Behavioral Techniques program
Transportation Selection
MethodTo CampFrom Camp
Airport Van: Flying campers arriving/departing from Phoenix Sky Harbor Airport ($75) ($75)
Personal Vehicle: I will provide my own transportation.($0)($0)
Grand Total
Medical Deposit$0.00
Cognitive Behavior Therapy$0.00
Grand Total Amount$0.00
Payment Information

Our published tuition fees reflect a 3% discount for direct payment. If you would like to charge the remaining tuition balance to your credit card, amounts charged will be 3% higher. We absorb this for the initial deposit of $500.00

(only for credit card)
Checking Account Information
e-Check logo
Credit Card Information
Credit Card logo
Card holder's Billing Information
Terms and Conditions Click to Print

By typing my name above (Digital Signature) I authorize Camp Shane, to withdraw funds from my bank account or charge my Credit Card and I agree to the terms and conditions on the Reservation Agreement, including authority to charge the balance due if the total amount owed are not timely paid as per the Agreement.