2017 Summer Camp Registration

 *****Complete one set of forms per child*****

Mail all forms and payment to:

Regina Gossage

13951  Freedom Center Lane, Leesburg, VA 20176

Checks made payable to Freedom Center Camp

Please fill out one set of forms PER CAMPER



- Each week is $150 for first child and $135 for each additional child, $50 non-refundable deposit required with forms.

-Balance will be due by June 30th for all camps


______July 10-14                 Wilderness/Survival Camp

______July 17-21                 Art Camp

______July 24-28                 Wilderness/Survival Camp

______July 31-August 4        Sports Camp

______August 7-11                  Christian Martial Arts / Self Defense Camp




Name of Camper: __________________________________ Date of Birth: ___________ Age (at the time of Camp): _______

Name you prefer to be called (if different): _________________________  Grade in September: _____  Male (  ) Female (  )

Camper lives with:  □ Father   □ Mother   □   Both Parents            □ Other___________________________________________

Name of Parent/Guardian/Primary Contact: _________________________________________________________________

Mailing Address: ___________________________________________________________________________

City: ______________________________ State: _______________________ Zip Code: ________________________

Home Phone: _______________________ Cell Phone: _____________________ Work Phone_____________________ Email address you check frequently:______________________________________________________

Best way to contact you?  (circle one)        Home Phone                                   Cell Phone                                Email        

3. EMERGENCY CONTACTS (please provide two additional people, different from the parent/guardian listed above, who would automatically be the first person we contact)

First Contact’s Name: ______________________________________ Relationship: __________________________

Home Phone: _____ - ______ - ______               Work/Cell Phone: _____ -______ - ______ ext ______


Second Contact’s Name: ____________________________________ Relationship: __________________________

Home Phone: _____ - ______ - _______             Work/Cell Phone: _____ -______ - ______ ext ______




Swimmer         Non-Swimmer  

Does your camper have any medical conditions, allergies, or special needs the staff should know about?



Does your camper have any fears, concerns, behavioral or emotional issues the staff should know about?



Briefly describe your child’s personality:





# of Weeks ______  x  $50 non-refundable deposit due immediately with forms: $________

Remainder of balance due : (postmarked by 6/30)  =          $________


 To complete your application, send all of the following:

□ Registration form signed by Parent/Guardian

□ Camper Health History form

□ Permission to Treat form

□ Deposit Check ($50/camper per week) payable Freedom Center Camp for all sessions registering for, mail to:

                                                            Regina Gossage

                                                            ATTN: Summer Camp Registration

                                                            13951 Freedom Center Lane

                                                            Leesburg, VA  20176




·        I request that my child be accepted to attend summer camp.  I verify that the information contained on this registration form and the Health forms are correct and complete.

·        I have read and understand the information provided by the camp, regarding policies, registration procedures, program descriptions and the activities listed for my child’s time at camp.

·        I have completed all required information and I have enclosed my payment.  I understand that representatives of camp cannot guarantee availability or reserve spaces over the telephone.

·        I understand that by signing this registration form I assume responsibility for payment of camp fees.

·        I understand the active nature of this camp program and give permission for my child to participate fully and to engage in all camp activities unless otherwise noted in the RESTRICTIONS section of the Health form.

·        Should it become necessary for my child to return home because of illness or other reasons, I will abide by the camp’s’ decision and arrange transportation for my child.

·        I understand that photographs and video footage of activities that may include my child will be used in camp promotional items and will occur without liability or remuneration.

·        In the event of a camp wide emergency, I give my child permission to be safely transported off the property.


I understand and agree with the contents of this registration document and program descriptions, and in signing below, am acting as the legal parent/guardian for the child being registered and am responsible for session and registration fees.



Parent/Guardian signature                                                                                                  Date