Camp ACCOVAC
Friday, September 22, 2017
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Camper Registration Forms

Camp ACCOVAC Youth Camp REGISTRATION FORM
It is very important that you PRINT CLEARLY and fill this form out COMPLETELY

Camper’s Full Name _________________________________ Nickname__________________
Address ____________________________________________e-mail______________________
Town __________________________________________State __________ Zip_____________
Telephone (      )________________Date of Birth ________ Age ____ Sex: M_____ F______
Grade in Sept. _________   Attended ACCOVAC before? YES/NO  If Yes, What Years __________
Camper's Church ________________________Denomination ______________
Church Address _________________________ Town________________State_____ Zip______
Church Telephone (      ) ____________
Church Contact Person: (Circle one) SS Teacher - Youth Pastor - Pastor ________________________
Parent's Regular Address (Write same if same as camper)________________________
Town ___________________________State____________Zip __________
Telephone (       ) __________

CHECK CAMP WEEK DESIRED  SUMMER 2017
Junior Camp I ..........................…….June 11-17.......... Ages 7-12
Junior Camp II.........................……..June 18-24 .......... Ages 7-12
Sport, Music & Drama .....................June 25-July 1........Ages 12-18
*Work & Wilderness Camp................July 2-8……….Ages 12-18
     * Must attend work portion of camp to earn privilege of Wilderness experience.
Cabin partner desired (not guaranteed) ___________________________________________
Enclosed please include a $25 non-refundable deposit per child, per week to register.

MAIL COMPLETED APPLICATION TO: Camp ACCOVAC - 33021 Mountain Valley Road -
Millboro, VA 24460

Registration is open to everyone without regard to sex, race or national origin
 
   IMPORTANT: THIS SECTION MUST BE COMPLETED BEFORE ATTENDING CAMP -
I hereby claim that I am the legal guardian and that the health information that I have provided is
accurate and that the person herein described has my permission to engage in all activities
except as otherwise noted. I hereby give permission to the medical personnel selected by the
Camp Director to order tests, and treatment in the event I cannot be reached in an emergency.
I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure
proper treatment for and to order injection and/or anesthesia and/or surgery. I understand that
my own insurance is primary before Camp ACCOVAC's insurance.  Additionally, this form may
be photocopied to be used outside Camp ACCOVAC if necessary.

Signature or Parent (Legal Guardian _____________________________Date _______
Witness___________________________________________________Date ________
 
 
 ***************************CONTINUE TO SECOND PAGE********************************************
 
 
 
 

Camper Conduct Agreement: Please read and sign the following agreement.
I agree to abide by all rules of behavior and conduct at Camp ACCOVAC. I understand that
violating these rules may result in expulsion from camp and forfeiture of all registration and
fees paid. I agree to conduct myself in a manner appropriate to the Christian environment at
Camp ACCOVAC.

Signature of Camper ______________________________________ Date_____________
Signature of Parent or Guardian______________________________ Date_____________
 
 
 
 
 
 
CAMP ACCOVAC YOUTH CAMP HEALTH INSURANCE/ MEDICAL QUESTIONNAIRE
The following information must be completed by parent or guardian of minors.
Name of Camper (last) ___________________________ (first) _______________________
Birth Date:___________________ Age _______ Sex: _______
Address:_________________________ Town_______________________
State :______Zip________
Parent (Legal Guardian)___________________________________
Telephone (        )______________
If not available in an emergency, notify __________________________
(Circle one) Friend / Relative
Address:_________________________ Town_______________________
State :______Zip________
Telephone: (       ) ______________
List Known Allergies ___________________________________________________________________
Operations or serious injuries (give dates) ______________________________________________
Disability or chronic/recurring illness ________________________________________________
Are there any specific activities that should be limited or avoided according to Physician’s orders?
Yes____ No_____ If yes, please explain ____________________________________________
Dietary modifications: ______________________________________________________________
Current medication(s) and dosage instructions _____________________________________________
_____________________________________________________________________________________
Hospital/Medical Insurance Carrier ____________________________________________________
Policy or Group Number _________________________________________________________
Insurance Company_________________________________________________________________
Address _____________________________Town________________State______zip_________
Telephone (       ) __________________
Name of Physician _______________________________Telephone (         )___________
Date of last physical exam ________
NOTE:  Head lice has been an occasional issue at camp in the past. If your camper has had lice recently
or been in close proximity to someone who has, please be sure that camper is completely free of any lice
and nits before coming to camp. Any camper found to have lice or nits will be sent home immediately.