Registration

See You This Summer.

CCYC would like to thank you for your interest in one of our weeks of camp. If you would like to preregister, please take a few minutes and fill out the form below. You may also register on the first day of camp, at CCYC.

Camp Fees.

$100 - Weeks of Camp (includes T-Shirt)
$30 - First Timers
$20 - Day Camp
Due on the first day of camp. Cash or check is accepted.

Questions?

If you have any questions regarding registration, don't hesitate to reach out to us.

Download Printable Form

2023 Camp Registration

* Indicates required field

Week of Camp *

Day Camp: June 3 -- $20 First Timers: June 9-10 -- $30 Junior 1 Week: June 11-16 -- $100 Senior: June 18-23 -- $100 Intermediate : June 25-30-- $100

Camp registration costs are due on the day of each week.

Camper's Name *

First

Last

Grade *

Age *

Address *

City *

State *

Zip *

Church *

Camper's shirt size (One shirt included) *

Child: Small Child: Medium Child: Large Adult: Small Adult: Medium Adult: Large Adult: XL Adult: XXL Adult: XXXL

Phone Number *

Email *

Emergency Contact Person *

Emergency Phone *

List anyone who has permission to sign your child out of camp: *

Health/Insurance.

CCYC's Insurance is of a secondary nature. Please list your primary insurance carrier and policy number. This information will be kept secure and will be used if your child has an emergency hospital visit.

Insurance Carrier *

Policy Number *

Permission to give Tylenol? *

Yes No

Health Comments *

Please list all important health and medical information (including all medications) that CCYC may need to know about the camper. *All medications MUST be turned into camp staff and should be in original prescription bottle.

Food Allergies *

At CCYC, we want to make sure your child is safe and will not be exposed to any food allergies he/she may have. If your child has any food allergies or special dietary needs, please describe them here.

Physical Activity.

I give this camper permission to participate in supervised swimming. *

Yes No

I give this camper permission to participate in CCYC's Adventure Course elements. *

Yes No

CCYC's Adventure course elements include: Ropes Course, Zip Line, 'Zorb' Balls, Kangaroo Jumper

I/we, parents/legal guardians of the above named camper, here acknowledge and request that I (or my child) participate in the above described sponsored activity by CCYC Inc., at 6312 Dry Fork Road in Vansant, VA, or other such accepted sites of CCYC Inc. It is understood that the above-described activity will be physical in nature and as with all physical activities; there exists certain risks and possibility of injury. I (we) hereby grant the authority for the staff of CCYC Inc. to render medical care (within their standards of care) in necessary, to transport and secure medical care for myself (or my child) in the event that medical attention is needed.

Furthermore, I (we) do hereby agree to hold harmless
from any and all liabilities, losses, expenses, or damages incurred: (1) CCYC Inc., and any staff members, employees, or their damages, which we have or which may hereafter accrue to us arising out of these incidents. I (we), the undersigned, have read, understood, and agree to the above.

Parent/Guardian *

Date *

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