Camp Bethel Traveling Day Camp 2019 Registration Form
THANK YOU for choosing Camp Bethel's Traveling Day Camp! This camp is open to everyone regardless of race, color, national origin, gender or disability where accommodations can match needs. Prior to registering for this program, please read our rules and what to expect at www.CampBethelVirginia.org/parentinfo.

We have restructured our Traveling Day Camp program for the 2019 summer. Program is FREE, but it costs us $38 per camper per day or $190 per week, so donate as much as you can.

The final item on this form is your "Parent/Guardian and Camper Agreement" with our Good Behavior Requirement, and your Parent/Guardian Authorizations for Attendance. (Is a Camp Bethel program a good fit for your camper? She/he will be with other children/youth and their counselors all day each day. We stay together with our group during our entire time at Camp Bethel. Bad behavior does not fit and cannot be tolerated.) By requesting enrollment into Camp Bethel programs, you and your camper agree to our Behavior Policy and understand that good behavior is required. See www.CampBethelVirginia.org/ParentInfo for details.

This is a LONG registration form; be sure to complete it thoroughly. SCROLL THIS FORM DOWN AS YOU GO, and be sure to click the SUBMIT button at the bottom of the form! Items with a red * asterisk are REQUIRED items.

Camper's LAST name *
REQUIRED. Thank you for using correct capitalization for names and titles throughout this registration form.
Your answer
Camper's FIRST name *
REQUIRED. Thank you for using correct capitalization for names and titles throughout this registration form.
Your answer
Camper's Middle Initial
Your answer
Gender - male or female *
Name Camper prefers to be called
Your answer
Grade (fall 2019) or age-grade equivalent *
REQUIRED. Generally, Campers are grouped with their same age-grade equivalent, (as well as their chosen group mate/friend).
Name of Friends to be in My Group
Since Units are generally grouped by same age/grade, write the full names of friends of similar age/grade & gender who are registered for this Day Camp and who you wish your child to be IN THE SAME DAILY ACTIVITY GROUP.
Your answer
Camper birth date *
REQUIRED. Month / day / year; example: 03/09/2004
Your answer
Age at camp *
REQUIRED QUESTION. When your child attends this camp, what will her/his age be?
Your answer
Your mailing address *
REQUIRED QUESTION: Street or PO Box. Thank you for using correct capitalization.
Your answer
City *
REQUIRED QUESTION. Thank you for using correct capitalization.
Your answer
State *
REQUIRED QUESTION. Note that Virginia is the first choice.
Zip *
Required: Zip code
Your answer
Full Name of custodial Parent(s)/Guardian(s) who is the primary contact for this camper. *
REQUIRED QUESTION. This is the parent/guardian(s) with whom the camper has primary residence and to whom we send camper information in care of. Example: Jane and John Doe
Your answer
Family e-mail
This is where we will e-mail your confirmation packet and camp preparation information. In emergency, we will also send important information by e-mail to this address. (We'll CALL you in case of extreme emergency).
Your answer
Main phone of custodial Parent/Guardian *
include area code, (ex: 540-555-1234)
Your answer
Other phone # of custodial Parent/Guardian
include area code, (ex: 540-555-1234)
Your answer
For which Day Camp are you registering your child? *
REQUIRED: From the pull down menu, select your DATES and your PROGRAM TITLE. If you wish to register for more than one camp week, you will need to complete a separate registration form for each program. But submit this form first! Thanks.
Getting to Know your Camper
The following questions will help us ensure a quality camp experience for your camper. Solicit your camper's thoughts as you complete these questions, remembering that our program focus is relational small-group community living.
Explain any special needs the camper has or significant information about this camper the Day Camp Director and your counselor should know in advance of her/his camper session. Include physical, emotional, or behavioral concerns.
Also list major medications your child takes for their health and well-being. If your child has SEVERE or UNMANAGEABLE allergies to common things, please contact Jenna Stacy before registering (540-992-2940, CampBethelOffice@gmail.com).
Your answer
Restrictions - Physical or Dietary
Your child will pack her/his daily lunch, but we will provide snacks each day. Explain any restrictions to diet, as well as activity (what cannot be done; what adaptations or limitations are necessary) restrictions. For any dietary restrictions, please give complete details about severity of needs.
Your answer
Describe your camper's personality when living, playing and working with others.
Your answer
How did you learn about this specific Day Camp OR about Camp Bethel's 2019 Summer Camps? *
PLEASE ANSWER THIS QUESTION! This information helps us greatly! Do our printing/advertising/mailing efforts work? Word of mouth?
Your answer
Church Membership (not required, but we're interested)
... if any. (This is NOT required for camp attendance, and ALL children/youth are welcome in our summer camps.) If you are from a Church of the Brethren congregation, PLEASE answer this question.
Your answer
PARENT/GUARDIAN and CAMPER AGREEMENT: Good Behavior Requirement and Parent/Guardian Authorizations for Attendance
GOOD BEHAVIOR REQUIREMENT:
Is a Camp Bethel program a good fit for your camper? She/he will be with other children/youth and their counselors all day each day. We stay together with our group throughout each day. Bad behavior does not fit and cannot be tolerated. By requesting enrollment into Camp Bethel programs, you and your camper agree to our Behavior Policy and understand that good behavior is required. Behavior deemed dangerous, inappropriate, intolerable, detrimental to the group, or unmanageable by the counselors or directors is grounds for dismissal from camp. Examples include: not following the camp rules; hurting others (verbally, physically, or emotionally); possession of prohibited or harmful item; constant misbehavior; unsafe behavior; straying from your group; etc. The Director will call parents/guardians as needed. Should it become necessary for your child to return home because of unmanageable behavior, homesickness or other reason, you have agreed to accept the Director’s decision and arrange for transportation.

PARENT/GUARDIAN AUTHORIZATIONS FOR ATTENDANCE:
I hereby request that my child be accepted to attend the Day Camp chosen above. I have read and understand this program's description and the activities listed for my child’s time at camp, and the Parent Information at CampBethelVirginia.org/parentinfo, including the camp rules and behavior policies. I understand that my child will be participating in many physical activities (including, but not limited to those listed in the program descriptions) and the potential for accidents exists. I understand that the camp and the host church have established guidelines to minimize risks to provide a safe environment and that Camp Bethel is licensed by Virginia to operate a Summer Camp, and that Camp Bethel is accredited by the American Camp Association in accordance to adherence to over 300 quality standards. In consideration of acceptance to Camp Bethel,
I indemnify and hold harmless Camp Bethel, the host site Church of the Brethren, the Virlina District Board–Church of the Brethren, Inc. and its staff and officers from any and all liability, claims, damage, injury or illness sustained by my child, and
I verify that the information on this Registration Form is correct and complete as far as I know. This information may be copied for camp records, and
For this camper I will complete and return a Health Form (link available after registering). I hereby give permission to the camp to provide routine health care, administer prescribed medications and over-the-counter medications I list on the Health Form, and seek emergency medical treatment. I agree to the release of any records necessary for emergency purposes. I give permission to the camp to arrange necessary emergency medical transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment for my child including ordering x-rays, administering tests, and admittance to a hospital, and
I understand that Camp Bethel provides only limited secondary medical insurance coverage for participants. I will attach proof of primary personal/family medical insurance coverage for my child, if any (this is optional and NOT required), as requested for camp attendance on the Health Form received in my confirmation packet after registering, and
I understand the active nature of the camp activities and give permission for my child to participate fully and to engage in all camp activities listed in the program description including archery, unless otherwise noted under the "restrictions" section of this application, and
I understand that archery activities are “challenge by choice” and that my child will not be forced to participate, and
I understand the cancellation/transfer and refund policies including (1) $25 of my payment is non-refundable unless Camp Bethel cancels the camp program, (2) a $20 processing fee must be added if I choose to switch or reschedule my camp date, (3) that if complete payment of the camp fee (or scholarship approval or Good-As-Gold form) is not received 14 days prior to my camp date I will forfeit my child’s reserved spot, (4) there are no refunds for cancellation of my reserved spot in camp within 14 days prior to my camp date, and (5) there are no refunds for partial camp attendance or early departure for any reason unless Camp Bethel cancels the camp program, and
I agree to read all information included in the Confirmation Packet and What-to-Bring List sent to me after registration and to share this information with the camper, and to read, sign and return any and all applicable forms including the Health Form (which will include Emergency Contact and "Who is authorized to pick up my child" information), and
Should it become necessary for my child to return home during the day because of illness, homesickness or other reason, I will accept the Director’s decision and arrange for transportation, and
I permit camp photos, video and audio of activities or interviews that may include my child to be used in camp promotion without liability or remuneration, and
I verify the Physical Assessment of this camper as described below.

Physical Assessment of Camper by parent, legal guardian or medical personnel: (We encourage parents/guardians to consult your child’s primary care physician to assess your child’s current health and physical abilities. Provide any updates or changes to this information at check-in on the first camp day.)
This child is physically able to participate in all camp activities listed in the program description (unless otherwise noted under the "restrictions" of this application), and I will provide an update to this child’s health status and Health Form, if any, during the health screening at check-in on the first day of camp.

I agree to the PARENT/GUARDIAN and CAMPER AGREEMENT, including the Good Behavior Requirement and the Parent/Guardian Authorizations for Attendance. *
After agreeing (clicking "YES"), be sure to SCROLL THIS FORM DOWN to the SUBMIT button in order to send us this camper information!
**To complete your registration, (1) click Submit, (2) print/save your Confirmation Packet, and (3) complete and return/submit your Health Form.
If you do not click "Submit" we will not receive your camper's information, so be sure to click SUBMIT. Thanks! Once submitted, you will be directed to a "Thank You" message with a link to your Confirmation Packet on our web site. Be sure to print/save your important Confirmation Packet the Day Camp you specifically signed up for.
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