Online Application

OPEN House – EVERY SUNDAY starting May 4, 2013 2:00 p.m. – 4:00 p.m. call to schedule an appointment.

Country Acres Camp Registration

2012 Camp Session

Day Camp Sessions are closed for this summer. We still have boarding camp sessions available July 7th and July 14th.
Sleep Away Camp Sessions
- July 7
- July 14
Please note:additonal "private" weekly boarding sessions may be opened for groups of 6 or more.
Camper Information
Camper's Name
FirstLast
Date of Birth
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Mother's Name
Mother's Work #
Father's Name
Father's Work #
Home Phone
Emergency Contact Information
List names of individuals who may be called if you can not be reached
Name
FirstLast
Phone
Name
FirstLast
Phone
If someone other than the parent will pick-up your child
list names of individuals who have your permission
Name
FirstLast
Phone
Name
FirstLast
Phone
List any special medical or social information about your child's growth & development that is critical to your child's well being:
List medical needs (if any) that need attention during camp hours:
Camp Activities not to participate in:
- Horseback
- Canoeing
- Swimming
- Archery
- Fishing
- Games/Sports
Email Address
Camp Staff or Campers sometimes take photographs for our website:
- Pictures OK for Web Site
- NO Pictures
Your electronic submission of this document indicates your consent to the expectations of Country Acres. However, your registration IS NOT COMPLETE without providing the following:
For Day Camp: A $40 registration fee is due per child. For Sleep Away camp: A deposit of 50% is due per child. Payment should be mailed to: Country Acres Summer Camp 25022 Loren Ladner Road Kiln, Mississippi 39556
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Online Application

Country Acres Camp Registration

Camper Information

Emergency Contact Information

If someone other than the parent will pick-up your child

Your electronic submission of this document indicates your consent to the expectations of Country Acres. However, your registration IS NOT COMPLETE without providing the following: