Virginia Nazarene Kids Camp Registration
Kidz Camp – July 9-13, Completed Grades 1-5

Camp Address: 1151 High School Rd., Buckingham, VA 23921

Registration Questions:

Email address *
Name of Camper *
Your answer
Sex *
Date of Birth *
Completed Grade *
Home Church *
Your answer
Pastor of Home Church
Your answer
Legal Guardian(s) *
Example: John Doe, Jane Doe
Your answer
Your answer
Your answer
Your answer
Phone (Home):
Your answer
Phone (Cell):
Your answer
Request Bunk Buddy
Only one, must be same grade & age.
Your answer
Shirt Size: *
Camper Shirts included/ leaders shirts $12
Media Release *
“Virginia District Children’s Ministries has permission to use images of my child in print, video, or digital media for the purposes of promoting and/or memorializing District Children’s Camps.”
Pickup Release
“In the event that my child would need to be picked up from the campgrounds, by someone other than a parent, the following list of persons is authorized for transportation of the child. I understand that only persons listed will be able to leave the campground with my child and that identification will be required before allowing any child to leave.” Please List the name of the person and the relationship to the child.
Your answer
Dietary restrictions *
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