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Register

Get in contact with us to register your camper.

Note: If you have more than one camper you'd like to register for Camp Crossroads, please only fill out this application once, and use the information for only one of the campers you'd like to enroll. In the "Comments or Concerns" box, state that you have another camper you'd like to enroll. We will reach out to you to discuss further steps.

Your Information

Your First Name

Your Last Name

Your Email Address

Your Primary Phone Number

Your Camper's Information

Applicant First Name

Applicant Last Name

Applicant DOB

Applicant Gender

Address

Apt/Unit #

City

State

ZIP/Postal Code

Your Relationship to Child

Does your child understand what substance use disorder is? If yes, briefly describe the impact.

Connection to St. Luke's Penn Foundation (if any)

Comments or Concerns

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