Lil' Otters Wednesday Family Canoe Registration Form 2019
THANK YOU for choosing Lil' Otters Family River Canoeing at Camp Bethel in Fincastle, VA! Your Family Adventure includes 5:30 dinner in our Ark Dining Hall, followed by a short canoe trip on the James River, and closing with a campfire and S'mores! Our programs are open to everyone of all ages regardless or race, color, national origin, gender or disability where accommodations can match needs.
Be sure to complete this form 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 small red asterisk (*) are REQUIRED items.
Family Last Name *
Thank you for using correct capitalization for names and titles throughout this registration form.
Your answer
How many participants are you registering for this Lil' Otters Family Adventure? *
This number should match the number of persons you already paid for AND should match the number of listed persons in the next question.
List all persons who will be participating PLUS their age, gender and shirt size (for lifejacket fitting) *
Ex: Jane Doe, 46, F, Adult Medium. Billy Doe, 11, M, Child Medium. Betsy Doe, 7, F, Child Extra Small.
Your answer
Your Mailing address *
Include Number, Street and/or PO Box. Thank you for using correct capitalization.
Your answer
City *
Thank you for using correct capitalization.
Your answer
State *
(Hint: VA for Virginia is listed first!)
Zip Code *
Your answer
Family e-mail
This is where we will e-mail your confirmation packet and camp preparation information.
Your answer
Home Phone of adult participant who is the MAIN contact for this activity *
include area code, (ex: 540-555-1234)
Your answer
Cell Phone of adult participant who is the MAIN contact for this activity
include area code, (ex: 540-555-1234)
Your answer
Lil' Otters Family Adventure Program Choice
From the pull down menu, select the program/date you are choosing for your family. This should match the program and date for which you have already paid!
Lil' Otters Family River Trip Dates & Title *
(Forget the exact name of your chosen program? Open another window/tab in your browser and check for an e-mail from PayPal confirming your payment AND the Lil' Otters Family Trip date for which you paid.)
Emergency Contact Information
In case of emergency or if we need to give important information to your family, but we cannot reach you, who should we contact?
Who to call in case of emergency
A trusted adult friend or relative who will NOT be going on this day trip with you.
Your answer
What is the relation of this person to your family?
Ex: Neighbor; My Grandfather; Work Colleague
Your answer
Home phone of your emergency contact person.
include area code, (ex: 540-555-1234)
Your answer
Cell phone of your emergency contact person.
include area code, (ex: 540-555-1234)
Your answer
Getting to Know your Family
The following questions will help us ensure a quality experience for your family. Again, a small red asterisk (*) indicates a REQUIRED question.
Will this be your family's 1st experience in a Camp Bethel program? *
List any NON-swimmers and their age(s) in your group.
Ex: Betsy Doe, 7, non-swimmer. (Remember that EVERYONE will wear a lifejacket while on the river.)
Your answer
Explain any HEALTH or MEDICAL CONDITIONS of any participant that would be important for the Camp Director and canoe trip leader to know about during this activity.
This is just so we can be aware in case of any emergency.
Your answer
Explain any special needs or environmental allergies of any participant that the Camp Director and your canoe trip leader should know in advance.
Please list any allergies and/or physical, emotional, or behavioral concerns you feel we should know about. If allergies, please list whether they are life-threatening and the exposure risk (airborne, in-gestation, skin contact, etc.).
Your answer
Physical Restrictions to activity of any participant
Explain what cannot be done and/or what adaptations or limitations are necessary.
Your answer
Dietary Needs or Restrictions for your dinner (and S'mores)
Please give complete details about severity of dietary needs, allergies or restrictions. If allergies, please list whether they are life-threatening and the exposure risk (airborne, in-gestation, skin contact, etc.).
Your answer
Please list any concerns you have about your Family Adventure.
This is very helpful for your activity leader to know so that s/he can immediately address any concerns.
Your answer
What are the outcomes from this camp experience that your family hopes for?
Your answer
How did you learn about Camp Bethel's Family Adventures?
PLEASE ANSWER THIS QUESTION! This information helps us greatly! Do our printing/advertising/mailing efforts work? Word of mouth?
Your answer
I/ We chose Camp Bethel because:
Your answer
Church Membership
... if any. (this is NOT required for camp attendance, and ALL families are welcome in our programs.) If you are from a Church of the Brethren congregation, PLEASE answer this question.
Your answer
Adult Authorization for Family Participation
I hereby request that my family be accepted to attend this Camp Bethel program. I understand that my family will be participating in physical activities (including, but not limited to those listed in the program description) and the potential for accidents exists. I understand that the camp has established guidelines to minimize risks to provide a safe environment and that Camp Bethel is licensed by Virginia to operate a Summer Camp, Dining Hall and Swimming Pool, 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 Virlina District Board–Church of the Brethren, Inc. and its staff and officers and the Episcopal Diocese of SWVA and its staff and officers and the James River Basin Canoe Livery (DBA Twin River Outfitters) and its staff and officers from any and all liability, claims, damage, injury or illness sustained by my family, 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
In case of a medical emergency during my family's participation I hereby give permission to the camp 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 family. In the event I am unresponsive during an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment for my famiyl 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 bring proof of primary personal/family medical insurance coverage, if any (optional and NOT required for participation), and
I understand the active nature of the activities and give permission for my family to participate fully and to engage in activities listed in my selected program description unless otherwise noted under the "restrictions" section of this form, and
Because this program includes transportation from Camp Bethel to the James River and back, I permit my family to be transported in camp-approved vehicles driven by camp-approved drivers including staff and vehicles from Twin Rivers Outfitters (Buchanan, VA), and,
I understand that (1) my $28 per person camp fee is non-refundable unless Camp Bethel cancels the trip due to severe weather or river conditions, (2) that if complete payment of the camp fee (or Good-As-Gold form) is not received 5 days prior to my trip date I will forfeit my family’s reserved spot, and (3) there are no refunds for partial program 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 Gear List sent to me after registration and to share this information with all participants, and to read, sign and return any and all applicable forms and any waivers (mostly applicable to Adventure and Trip programs), 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 all participants as described below.

Physical Assessment of Activity Participants by parent, legal guardian or medical personnel: (We encourage parents/guardians to consult your primary care physician to assess each participant's current health and physical abilities. Provide any updates or changes to this information upon arrival at camp.)
Each participant is physically able to participate in the activities listed in my selected program description (unless otherwise noted under the "restrictions" of this application).

I agree to the Parent/ Guardian Authorization. *
After agreeing (clicking "YES"), be sure to SCROLL THIS FORM DOWN to the SUBMIT button in order to send us your family's information!
**To complete your registration, (1) click Submit, and (2) print/save your Confirmation Packet.
If you do not click "Submit" we will not receive your information, so be sure to click SUBMIT. Thanks! Once submitted, you will be directed to a "Thank You" message with a link to the Confirmation Packets page of our web site. Be sure to print/save your important Confirmation Packet.
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