Camp Burt Shurly 2018 Camper Application Complete this form and mail to: Camp Burt Shurly, 15100 Goodband Rd, Gregory, MI 48137.

Phone: (734) 389-9587 /Fax: (517) 548-7373. A parent or legal guardian MUST SIGN the application. When your application is received, a medical form and confirmation letter will be sent to you explaining Camp Burt Shurly (CBS) procedures and a suggested list of needed articles for your stay at camp. CBS will not discriminate against any individual / group because of race, sex, religion, age, national origin, color, marital status, handicap or political beliefs.

Camper’s Name: _____________________________________________ Home Phone: (____)__________________ Parent Name: _____________________________________________Secondary Phone: (____)_________________ Full Address: ___________________________________________________________________________________ Street Address City State Zip

Best E-mail Address: _____________________________________________________________________________

Boy: Girl: Age: ________ Birth Date: ______________________Upcoming School Grade: ___________ Emergency Contact (Not a Parent): _____________________________________ Phone: (____) ________________ Name of School: __________________________________ Name of Teacher________________________________

Please Read and Sign Below: I understand that there will be physical activities of which my child may participate and that my child may be exposed to the possibility of injury. I hereby expressly waive any and all liabilities on the part of Detroit Rescue Mission Ministries (DRMM), Detroit Public Schools Community District (DPSCD), and their staff for any such injury. I give permission for routine medical treatment to be administered to my child. In case of an emergency, and I cannot be contacted, I give permission for DRMM staff to select a licensed physician and authorize the physician to secure proper treatment for my child. I understand that photos and/or videos may be taken of my child while at camp. I give permission and consent for my minor child to be photographed and videoed during camp activities. I further give my permission and consent that any such photographs and videos may be published and used by DPSCD, DRMM, the American Camp Association and its agents to illustrate and promote the camp experience through literature, videos, website or outside advertisement and marketing. All camps are co-ed. When your application is received a medical form and a confirmation letter will be sent to you explaining camp procedures and a suggested list of needed articles for your child’s stay at Camp Burt Shurly. If you have additional questions, please call the camp office (734) 389-9587 or visit www.campburtshurly.org.

Names of persons other than parent to whom child may be released: 1.______________________________________________2. _____________________________________________ Names of persons to whom child may NOT be released: 1. ______________________________________________2. ____________________________________________ Sign below, then choose your FREE week of camp on the back of this application.

Parent Approval: I approve this application and agree to the terms stated herein:

_________________________________________ Parent / Guardian Signature

_________________________________________ Print Name of Parent / Guardian

OFFICE USE ONLY – CHECK OUT: _________________________________________ Signature of Parent / Guardian

DO NOT RETURN THIS APPLICATION TO THE SCHOOL! MAIL IT TO THE CAMP AT THE ADDRESS ABOVE.

✔ Bus Pick Up and Drop Off Locations Week of Camp Cost

WesternInternationalHighSchool1500ScottenStreet,Detroit,MI48209

July 1-July 6 Free

EmersonElementary–MiddleSchool18240HuntingtonRoad,Detroit,MI48219

July 8-July 13 Free

FisherMagnetUpperAcademy15491MaddeleinStreet,Detroit,MI48205

July 15-July 20 Free

HutchinsonElementary–MiddleSchool2600GarlandStreet,Detroit,MI48214

July 22-July 27 Free

WesternInternationalHighSchool1500ScottenStreet,Detroit,MI48209

July 29- August 3 Free

Golightly Education Center 5536 St Antoine Street, Detroit, MI 48202 August 5- August 10 Free

DROP OFF & PICK UP INSTRUCTIONS Buses will pick up campers to transport them to Camp Burt Shurly on Sundays at 3:00 PM at the locations identified in the chart above. Registration will not begin before 3:00 PM. A parent or legal guardian must be present to complete the registration process when dropping off a camper. Campers arriving at the bus stop after 3:30 PM may have your space given away. Please be on time!

The bus will return campers to the same location on Fridays at 2:00 PM. Please be on time picking up your child! If you are picking up your child from camp, you should arrive at the camp office at 1:00 PM.

Camp Burt Shurly offers an exciting residential summer camp experience to Detroit Public Schools Community District students ages 8 to 12 years of age. There is NO COST for this experience. Campership includes transportation, activities, lodging & meals. Our goal is simple – to help kids experience an increased love for learning, expand an affinity for nature, gain a higher level of self-esteem, learn to facilitate healthy conflict resolution & create healthy life-long goals!

CHOOSE YOUR WEEK