Create an Account
= Required Fields

Account Type

Select Account Type:

Primary Contact for account

Enter the information for the primary contact for this account. This person must be an adult.
First Name:

Last Name:

Middle Initial:
Nickname:
Gender:
Birth Date:

mm / dd / yyyy
Address:

City:

Country:
*
State / Province:
*
Zip / Postal Code:

Primary Phone
*



Alternate Phone:
*
Ext.



Alternate Phone 2:



E-mail Address:
*
Confirm E-mail Address:
*

Additional Contact for account

Add an additional contact for this account by completing the information below.
This person is:
First Name:
Last Name:
Middle Initial:
Nickname:
Gender:
Birth Date:

mm / dd / yyyy
Address:
 
City:
Country:
Sate / Province:
Zip / Postal Code:
Primary Phone:


Alternate Phone:
Alternate Phone Ext:

Alternate Phone 2:

E-mail Address:
Confirm E-mail Address:


Additional Information

Please provide the following information
Please let us know how you first heard about us. If you were referred to us by an alumnus or current family, please give their name: there is a referral discount for you, and, if they are a current Ballibay family, a discount for them as well. Thank you!
*
Performances at camp are only open to members of the Ballibay Ensemble. The Ballibay Ensemble includes current and former Ballibay campers, current and former employees of Camp Ballibay and campers' family members. There are no responsibilities or fees associated with being a member of the Ballibay Ensemble. If you would like to authorize others to come see your camper(s) in performances at camp, please enter their full names below.

Login Information

The username and password must consist only of letters and/or numbers.  No special characters or spaces are allowed.
Username:
Password:
*
Confirm Password:
*
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1660 Ballibay Road   •   Wyalusing, PA 18853   •   570-746-3223   •    Fax: 570-746-3691

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