Winter Camp Registration Form: Dec 29-30
Camp Bethel (Fincastle, VA) programs are open to everyone regardless of race, color, national origin, gender or disability. Once you have submitted your registration, click the SUBMIT button at the bottom. Required questions have a red "*" asterisk.
Camper's LAST name *
Thank you for using correct capitalization and punctuation throughout this form!
Your answer
Camper's FIRST name *
Thank you for using correct capitalization and punctuation throughout this form!
Your answer
Camper's Middle Initial
Your answer
Name Camper prefers to be called
Your answer
Gender - male or female *
Grade (2018-19 school year) or grade equivalent age group *
Camper birth date *
month / day / year; example: 03/09/1999
Your answer
Age on December 29 *
Mailing address including street or PO Box *
Thank you for using correct capitalization and punctuation throughout this form! Thank you!
Your answer
City *
Your answer
State *
Note that VA is the first choice.
Zip Code *
Your answer
Full Name of custodial Parent(s)/Guardian(s) who is the primary contact for this camper. *
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/Cell phone of custodial Parent/Guardian *
include area code, (ex: 540-555-1234)
Your answer
Work phone of custodial Parent/Guardian
include area code, (ex: 540-555-1234)
Your answer
Cabin mate(s) requested (or Unit Friend(s) for friends of different genders)
Units are generally grouped by same age/grade and cabins are grouped by gender plus age/grade.
Your answer
Who will pick up your child on Sunday at 2:00? List all adults who are authorized to drive the camper home from camp: *
Your answer
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 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 Barry LeNoir before registering (540-992-2940, CampBethelOffice@gmail.com).
Your answer
Restrictions - Physical or Dietary
Explain any restrictions to activity (what cannot be done; what adaptations or limitations are necessary) or dietary restrictions. For any dietary restrictions or food allergies, please give complete details about severity of needs. For example, is this dietary restriction life-threatening or a matter of conscious?
Your answer
As your camper thinks about the upcoming camp time, what EXCITES and CONCERNS her/ him?
Re-read the camp brochure and program description(s) to ensure expectations match what will really happen.
Your answer
How did you learn about Camp Bethel?
Your answer
Church Membership
... 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
Pastor
... if any. (this is NOT required for camp attendance.)
Your answer
Parent Authorization
I hereby request that my child be accepted to attend Camp Bethel. I have read and understand the information in the summer camp brochure, including parent and camper information, the camp rules and behavior policies, registration procedures, cancellation policies, the program descriptions and the activities listed for my child’s time at camp. 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 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 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 Camper 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, as requested for camp attendance on the Health History 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 my selected program description including the group challenge & initiatives course, climbing wall, high ropes course, and archery, unless otherwise noted under the "restrictions" section of this application, and
I understand that climbing at any height, using climbing equipment (climbing wall/high ropes course) and archery activities may have inherent risks and that participation may involve accidents that could result in injury. I understand that climbing wall, high ropes and archery activities are “challenge by choice” and that my child will not be forced to participate, and
By registering my child into a program which includes transportation off site (ex: adventures, trips, service projects), if applicable, I permit my child to leave the grounds of Camp Bethel accompanied by authorized camp personnel for approved out-of-camp activities at camp-approved locations, to be transported in camp-approved vehicles driven by camp-approved drivers, and, if applicable while off site, for camp personnel as authorized by the Director in consultation with the Health Coordinator to administer prescribed medications and over-the-counter medications to my child as listed above, and
I understand the cancellation/transfer and refund policies including: (1) $50 of my camp fee 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 Packing List sent to me (or linked 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 History Form and any waivers (mostly applicable to Adventure and Trip programs), and
Should it become necessary for my child to return home 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 my selected 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 History Form, if any, during the health screening at check-in on the first day of camp.

I agree to the Parent/ Guardian Authorization above *
Payment method: How will you pay for this program? (...and don't forget to click SUBMIT below!) *
**To complete your registration, click Submit, then complete payment as indicated above. Thank you! Now, CLICK SUBMIT!
If you do not click "Submit" we will not receive your camper's information.
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