My Web Application - Create Enrollment

Important!

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.

Location *

Camper Information

First Name *

Last Name *

Gender *

MaleFemale

Date of Birth *

Camper's age as of July 1st

Grade

Address *

Street 2

Country *

State *

City *

Postal / Zip Code *

Home Phone *

Cell Phone

Camper's E-mail

Verify Email

Height *

Feet

Inch

Weight (pounds) *

How did you first learn about us? *

Was a relative/family member a Camp Shane camper or staff alumni?

YesNo

Name of Relation

Parent/Guardian Information 1

First Name *

Last Name *

Relationship *

Street *

Street 2

Country *

State *

City *

Postal / Zip Code *

Cell Phone *

Home Phone *

Email *

Verify Email *

Employer

Work #

Parent/Guardian Information 2

First Name

Last Name

Relationship

Street

Street 2

Country

State

City

Postal / Zip Code

Phone2

Cell Phone

Home Phone

Email

Verify email

Employer

Work #

Health Insurance Information

Policy Holder Name

Health Insurance Co

Group #

Insurance ID #

Rx Policy #

Policy Holder’s Birth Date

Employer’s Name

Insurance company's address

City

State

Postal / Zip Code

Please check any session you would like to attend.*

Session	Weeks	Tuition	Select	Extension **
Session 1 Jun 07 to Jun 21	2	$2,675.00		June 07 - June 28
Session 2 Jun 21 to Jul 05	2	$2,675.00		June 21 - July 12 June 14 - July 05
Session 3 Jul 05 to Jul 19	2	$2,675.00		June 28 - July 19

Medical Deposit * Medical deposit is fully refundable, less any portion used. Refund checks are issued by the end of October, after camp.

Medical Deposit *

Cognitive Behavioral Techniques program

Enroll my child in CBT

Transportation Selection

Method	To Camp	From 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

Item	Cost
Session	$0.00
Medical Deposit	$0.00
Cognitive Behavior Therapy	$0.00
Transportation	$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

Payment Method

Credit Carde-Check (U.S. residents only)

Enrollment Deposit *

Additional Amount

Surcharge

(only for credit card)

Total Amount *

What is additional payment for (Tuition/Trip/Etc)

Checking Account Information

Routing # *

Account # *

Credit Card Information

Credit Card # *

Expiry Date *

CCV *

Card holder's Billing Information

First Name *

Last Name *

Street *

Street 2

City *

Country *

State *

Postal/Zip Code *

Phone *

Email *

Verify Email *

Terms and Conditions Click to Print

Digital Signature *

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.