Valley Harvest Ministries - Free Camp Application

Camper's Information

Camper's First and Last Name

Camper's Birthdate

Camper's Age

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Gender

Parent/Guardian Email

Parent/Guardian Phone Number

Family/Emergency Contact Information

In case of emergency or at camp dismissal, TWO of the listed contacts must be available and in town during the camp.

Parent/Guardian's First and Last Name

Relationship to the Camper

Best Phone Number to Reach Parent/Guardian

Is this person authorized to pick up the camper>

Yes

No

Emergency Contact #1 First and Last Name

Emergency Contact #1's Relationship to Camper

Best Phone Number to Reach Emergency Contact #1

Can Emergency Contact #1 Pick Up the Camper?

Yes

No

Emergency Contact #2 First and Last Name

Emergency Contact #2's Relationship to Camper

Best Phone Number to Reach Emergency Contact #2

Can Emergency Contact #2 Pick Up the Camper?

Yes

No

Church/Miscellaneous Information

Church You Attend

City/State of Church

We were invited to Free Camp by:

My camper has been to Free Camp before:

Yes

No

T-Shirt Orders

T-shirts will only be available for those that turn registration forms in by May 1, 2024

Camper's Signature

Please check that you have read and understand/agree to the following:

I understand that I must follow all camp rules and obey all camp staff.If I do not, I will not be allowed to participate, and if necessary, I will be sent home.

Camper's Signature

Registration Form

Please ensure you read and complete ALL portions of this registration form.

We are unable to accept incomplete forms; incomplete forms will be returned for completion.

Please contact us if you need assistance or if you have any questions. Thank you!

Insurance Information

Name of Insured (Policy Holder)

Medical Insurance Company

Employer:

Policy/Certificate #

Employer Group Number

Medical History

If you checked "Other," please describe:

Medicine/Food Allergy List

Please recognize that Free Camp utilizes physical and outdoor environments. However, we recognize that some have physical/mental limitations/restrictions. Please list ALL that apply.

Medication Administration

Please check that you have read and understand/agree to the following medication administration policy::

Medications accompanying youth to camp must be presented to camp officials upon arrival. All medication must be in the original container. A written request from parent/legal guardian must accompany all medication stating dosage and time to be administered. Medication WILL NOT be given without this permission. Over-the-counter treatments may be implemented by the staff for minor illnesses, if needed. No aspirin or products containing aspirin will be administered. Medications that are not picked up at end of camp will be properly disposed if not collected in a reasonable time frame.

Release/Authorization

I prefer this physician to be contacted, if convenient and practical.

Please check that you have read and understand/agree to EACH of the following points:

I, the undersigned parent/legal guardian, hereby grant permission for my child to participate in the pre-arranged activities relating to the camp, including travel to and from such pre-arranged games and events.

I hereby, for and in consideration of the activities with Valley Harvest Ministries of Dublin, Virginia, do hereby authorize any adult staff member to secure, obtain, or otherwise see to all medical care/treatment, including any emergency operation requiring anesthesia which, in the opinion of said adult and in consultation with competent medical personnel, may be necessary as a result of injuries or illness sustained by said child while engaged in camp-related activities.

I do hereby further release said Valley Harvest Ministries of Dublin, Virginia, from any and all claims, demands, actions, or causes of actions made by me or any other person under my direction of control by virtue or as a result of any injury or illness sustained by aforementioned child while engaged in any camp-related activity. I accept responsibility for payment of expenses incurred as a result of medical treatment.

I do hereby further authorize said Valley Harvest Ministries of Dublin, Virginia, to publish and/or present any recorded media of said child in the advertisement or promotion of Free Camp and its activities. I also recognize and understand that my aforementioned child MUST obey the rules and regulations of the camp or he/she will not be allowed to participate and, if deemed necessary, will be sent home.

Parent/Guardian Signature

Additional Camp Information

Campers (7-12)

Held on the campus of
Valley Harvest Ministries
1 Harvest Place, Dublin, VA 24084
(across from Walmart, behind O'Reilly and Taco Bell)

Spaces are limited and first come, first served so get your application in ASAP. (If you have any questions, contact Sharon Webb at 540-599-5160 or church office Mon-Thur. 9 am – 5 pm at 540-674-4729)

Campers may begin checking in for camp at 8:00 am on Friday at Valley Harvest Ministries, Dublin. CAMP DISMISSAL is on Sunday after morning service at Valley Harvest Ministries. Parents are encouraged to attend the service and transportation is provided, if needed.

A parent/legal guardian or authorized emergency contact must personally withdraw campers through Registration before a child can leave the event or at camp dismissal.

Transportation IS provided to or from the event, if needed. Contact Sharon Webb if transportation is needed at 540-599-5160

All Campers should follow the
Four Rules, One Attitude Principle

1, RESPECT all facilities and all people in them.
2. REMAIN in the area until the event is over.
3. STAY IN the boundaries of camp and camp events & STAY OUT of areas only for a specific gender.
4. OBEY all leaders.

Attitude: CHRISTIAN CONDUCT should be displayed at all times!

Free Camp Application
June 20-22, 2025
Ages 7-12

Camper's Information

Family/Emergency Contact Information

Church/Miscellaneous Information

T-Shirt Orders

Camper's Signature

Registration Form

Insurance Information

Medical History

Medication Administration

Release/Authorization

Additional Camp Information

About

CONTACT US

Free Camp ApplicationJune 20-22, 2025Ages 7-12

Camper's Information

Family/Emergency Contact Information

Church/Miscellaneous Information

T-Shirt Orders

Camper's Signature

Registration Form

Insurance Information

Medical History

Medication Administration

Release/Authorization

Additional Camp Information

About

CONTACT US

Free Camp Application
June 20-22, 2025
Ages 7-12