CAMP MARIASTELLA                                Standard
                                              Registration--Summer Camp, 2022
        Business Office:   4316 Lanai Road, Encino, CA  91436               Phone: 818.285.1555   Fax:  818.285.1556
        E-mail:  campmariastella@aol.com                       Web site:  www.CampMariastella.com 
        This form and $20 deposit must be received by the Camp office to confirm registration.
        Please print all information:
        Camper’s name_____________/____________________ Shirt: child size _____ or adult size: __________
                                            Last                        First
        Age when at camp_______/________                Date of Birth: _______/______/______
                                                years       months                                                      month      day       year
        Address: ____________________________________                     Home phone: (____) __________________
                                                          Important
                 _________________________      ________    Please   Parent Email: _______________________
                                     City        Zip      Provide
        Custodial Parent/Guardian: _____________________ Bus. Phone: ____________ Cell Phone: ____________
               Occupation___________________________   Relationship to Camper_________________________
               Home Address: (if different) _________________________________________________________________________
               E-mail address: ___________________________
         nd
          2    Custodial Parent/Guardian : __________________Bus. Phone: _____________ Cell Phone: ____________
               Occupation___________________________   Relationship to Camper_________________________
               Home Address: (if different) _________________________________________________________________________
        Where will parent(s) be while child is at camp?  _________________________________________________
        If parents not available in emergency, Contact Person___________________Home #___________________
        Must be different numbers than above.   Cell #__________________         Bus. #____________________  
        Camper lives with:  Both parents       Mother only        Father only     Other_____________
        Has camper been to Mariastella before? ________     What year(s)?  _________________
        Has camper been to other camps before? ________    What year(s)?  _________________
        Did camper enjoy it & why? ________________________________________________________________
        Parish/Church: __________________________     School________________________ Grade in Sept. _____
        Camper’s religion: ______________________
        What do you want your child to learn or do while at camp? _________________________________________
        When available, is swimming instruction desired? ________     Any restrictions?  _______________________
        Is camper able to participate in hiking program?  _________    Any restrictions?  _______________________
        Explain restrictions:  _______________________________________________________________________
        Describe your child (i.e., hobbies, interests, etc.): ________________________________________________
        ________________________________________________________________________________________
        ________________________________________________________________________________________
                                                                   st     nd
          WHICH CAMP SESSION DO YOU PREFER?  (Indicate 1     and 2     choice.) 
          1. July 5 – 8: Leadership Camp: Ages 12 – 16 Only: 45 Spots Available
          2.   July 18 – 23: Girls Camp
          3.   July 24 – 29: Co-Ed Sibling Camp
          Bus Pick-up points:  Please check the CITY below where your daughter will board the bus, unless you will drive 
          her.
          Check here if you will drive your daughter up to camp: 
          Check here if you will pick up your daughter from camp:          
          Additional pick-up points may be added if there are at least five or more campers from same location. Call camp office to 
          arrange.
          Session 1   TBD Based on Location of Accepted Applicants
          Session 2      Los Angeles        Upland            Encino           Lakewood             Victorville*      
          Session 3    Los Angeles          Upland            Encino           Lakewood             Victorville*
                                  *We will need at least 7 campers at this location to have this bus pickup
          Total cost for the camp session is $200 per camper.  
          A deposit of $20 (non-refundable, but applicable to total camp fee) must accompany registration papers.  The
          camper will be registered for the session indicated, in the order in which the registration papers are received at 
          the Camp Mariastella Office.
          Camperships are available for families needing financial assistance in paying the Camp fee.  If you are requesting a
          campership ,   please check here : . You will still need to send a $20 deposit with this registration form.
          Photos generally taken during summer sessions may be used for promotion. I give permission for my child’s 
          photo to be used.  
            
          Parent/Guardian Signature________________________________________                Date_____________________________
          Witness_______________________________________________________                   Date____________________________
          OFFICE USE ONLY
          Session _________                         Pick up: _____________     Drop Off: _____________                                  
          HI          CF         TF
          Deposit $_______ Check #________Date Rec’d ___/___/___        Balance Paid $_______    
          Campership Submitted: Y / N   Campership Approved: Y / N     Campership Amount $________
    Notes: 
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