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home
Counseling Services
>
adults
teens/adolescents
Children
Couples
Contract Services
School Services
Forms & FAQs
Statesboro Team
Atlanta Team
Contact Us
Join Our Team
Online Registration - Managing Anger
PLEASE NOTE: If the camper is under 18 years old, this form must be completed by the Parent or Legal Guardian who has the right to make medical decisions for the child.
*
Indicates required field
Camper Name
*
First
Last
Gender
*
Male
Female
Other
Date of Birth
*
Age
*
Street Address
*
City
*
State
*
Zip Code
*
Parent/Guardian Contact Name
*
First
Last
Phone Number
*
Email
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Address (if different from above)
*
Please indicate the camp you are registering for:
*
June 10th - 14th, 9 AM- 12 PM, Ages 10 to 17
June 24th - 28th, 9 AM- 12 PM, Ages 4 to 9
List any allergies (medication, food, or other):
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Is an Epi-pen required for any above allergies
*
Yes
No
List any special needs/ considerations:
*
List any dietary restrictions:
*
Payment Information:
Cost is $200 per person per camp. If the participant has a developmental disability and you need financial assistance please contact Easterseals Middle Georgia at (478) 275-8850 or Pineland BHDD at (912) 764-6906.
We are in network with certain insurance companies, but payment for camps will depend on benefits of your plan. All insurance companies we can take are listed on the flyer. If interested in using insurance, please provide the insurance information below.
*We will only charge the credit card for any amount that insurance doesn't cover. We will also contact you before charging the card.
Name on Credit Card
*
Credit Card Number
*
Expiration Date
*
CVV Code
*
By typing your name below you agree to allow Brave Tomorrow Counseling to charge your card $200
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Insurance Company
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Member ID
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Comment
*
Submit
