Registration: Please enable JavaScript in your browser to complete this form. - Step 1 of 6Email *Email PreferencesPlease Add Me to Koinonia's Mailing ListCamper's Name *FirstLastName Camper Likes to Be Called *Camper's Email *Camper's Gender *Choose OneGirlBoyTransgenderNon-binary/QueerCamper's Date of Birth *Camper's Grade Next School Year (2022-2023) *Choose onerising-5th graderising-6th graderising-7th graderising-8th graderising-9th graderising-10th gradeList all languages spoken fluently by camper *Primary Adult Contact's Name *FirstLastRelationship to Camper *Occupation/EmployerPreferred primary method of contact *PhoneTextEmailPrimary email or phone number *Secondary method of contact *PhoneTextEmailSecondary email or phone number *Third email or phone numberAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryHow did you hear about Camp Koinonia? *SchoolFriendMentorCommunity ProgramCamp Koinonia StaffCamp Koinonia WebsiteOther WebsiteFlyerSocial MediaOtherAre you receiving assistance with this registration process? *No, I'm completing my child's registration alone.Yes, I'm receiving help with language interpretation/translation.Yes, I'm receiving help with computer/technical support.If yes above, please provide the name of the individual providing assistance, any affiliated group or organization, and phone/email address for the person providing assistance. NextSecondary Adult Contact's NameFirstLastRelationship to Camper *Occupation/EmployerPreferred primary method of contactPhoneTextEmailPrimary email or phone number *Secondary method of contactPhoneTextEmailSecondary email or phone number *Third email or phone numberAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPreviousNextShort AnswerPlease answer each question with one or two sentences. Be honest, and do your best. ATTENTION PARENTS: This section is to be filled out by your child only, in their own words. Please do not impersonate your child. These answers do not help or hinder a child's acceptance to camp. We use this section to learn about our campers' knowledge and interests. We also use a few answers for games and activities during camp, so it's important that answers are in the campers' own words. The answers on this form are mine, the camper's: *I affirmWhat are your favorite hobbies or activities? *What are three of your talents or strengths? *How would you define a human right? Can you name any human rights off the top of your head? *Are there any specific peace and justice issues that you are interested in? How did you become interested in these issues? *What is one way you’d like to see the world change? *We want to make sure all campers feel comfortable and respected. Is there anything that we should know about you or your personal experiences before you come to camp? Your answer is confidential.Questions? Comments?PreviousNextIn our work toward ensuring diversity of campers at Peacebuilders Camp, we ask that you help us by sharing a little information about your camper’s background. This section is optional. School camper will be attending in the fallPublicPrivateCharterHomeschoolOtherGenderGirlBoyTransgenderNon-binary/QueerEthnicity/RaceBlack or African-AmericanLatinx/HispanicWhite or CaucausianAsianPacific IslanderNative AmericanMiddle EasternReligious AffiliationMuslimChristainJewishBuddhistHinduAgnosticAtheistDoes the camper identify as a person with disabilities or as someone who is differently-abled?YesNoCamper's Place of Birth (Nation, State, City)Parents' Place of Birth (Nation, State, City)Languages spoken at homeIs the camper a refugee?YesNoHousehold IncomeLess than $10,000/year$10k-$25k/year$25k-$50k/year$50k-$75k/year$75k-$100k/yearMore than $100k/yearPreviousNextList persons other than Primary and Secondary Adult Contacts who can either pick up and/or assume responsibility for your child(ren) in the event of an emergency if Primary & Secondary Contacts cannot be reached. Emergency Contact #1 Name (not primary or secondary adult listed previously) *Emergency Contact #1 Phone *Emergency Contact #2 Name (not primary or secondary adult listed previously)Emergency Contact #2 PhonePreviousNextThank you for registering for Camp Koinonia! If you have any questions, please don't hesitate to contact us by email at quayneshia@koinoniafarm.org.The total amount for our full week of camp is $750.00. The price includes: lodging, activities, food and day trips. Please reach out to inquire about our sliding scale option or questions on payments. A link to pay for camp online will be in your confirmation email after you submit this form.PreviousPhoneSend