Camp Catalyst Application

Camp Catalyst Application

810 West 21st Street, Houston, Texas 77008
Camper Information
Camper Name

First NameLast Name
Birth Date

MonthDayYear
Camp Session
Grade
Camper's School for 2023/24
What is your child's pronoun? This helps us know how to address your child. For example, choose she/her if you would like us to say "she is celebrating a birthday today!"
T-shirt Size
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
We prepare our own lunches. Does your child have any allergies? If yes, please describe.
Is your child prescribed an inhaler or medications? If yes, please explain any instructions.
What would you love us to know about your child?
Whom should we thank for referring you?
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Catalyst Counseling,LLC during the selected camp. In exchange for the acceptance of said child’s candidacy by Catalyst Counseling,LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Catalyst Counseling,LLC and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Catalyst Counseling,LLC . including all satff, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Payment
prevnext( X )
9:00am to 2:00pm Camp
$750.00



9:00am to 2:00pm Camp for Returning Camper or Sibling
$650.00



partial scholarship
$350.00



Total

$0.00
Payment Methods

Please click one of the PayPal options to complete payment and submit the form.
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