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.
Camp Fees are due on the first day of camp.
Cash or check is accepted.
There are scholarships available to pay in-full for 1 full week
Prices do include T-Shirt

Questions?

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

Download Printable Form

2025 Camp Registration

* Indicates required field

Week of Camp *

Day Camp: $20 First Timers: $30 Junior 1 Intermediate 1 Senior Junior 2 Intermediate 2

Camp registration costs Junior 2 Date: July 6th-11th Dean: Matt & Sam Lee Grade: 3rd-5th Registration: 3:00 PM Sunday 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 & Waterslide. *

Yes No

I give permission for children to have pictures taken by CCYC staff and posted on social media *

Yes No

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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