2025 Virginia Camping Ministry

Cancellations and Postponements

All attempts will be made to notify registrants no later than three weeks prior to the start of the event if an event must be postponed or canceled. If your event is canceled, we will apply the full registration fee to a future event or provide a full refund.

A Parent/Guardian for this registration will provide their digital signature via a checkbox for the "Permission to Photograph" and "Consent and Release" sections.

A Parent/Guardian and Camper for this registration are providing their digital signature via a checkbox for "Community Covenant."

To complete a Registration, YOU WILL NEED the following information for Each Camper.

Camper Name
Date of Birth
Gender
Grade completed(this June)
Mailing Address, City & Zip
Email Address of Parent/Guardian that is checked.
Name & Phone Contact for parent/Legal Guardian.
1 Emergency Contact IF parent cannot be reached (Name & Best phone number)
Name of Your Church & City
Medical Information (ie: insurance, Doctor name and number)
If the camper takes medication, we will need that list with dosage information.
Vaccination history (yes/no)
Emotional/Social Health Questions
General Health Questions
FOR REQUIRED ITEMS, PUT N/A IF DOES NOT APPLY
PAYMENT: If you do not belong to a Disciples Church or if your church is NOT paying all of your fee, please pay using this link (please choose VA Region Camp Program) or send a check to CCINVA, 1290 Enterprise Dr, Lynchburg, VA 24502 with memo stating which camp. https://www.ccinva.org/online-giving

CLICK the radio button for the Camp you are registering for:

Triple 1: July 6-11, 2025 ($365.00)
Completed Grades 3-12
New Covenant: July 20 -24, 2025 ($300.00)
Completed Grades 1-5

Camper Name

PREFERRED name

Date of Birth

Grade completed June 2025

Gender

Male
Female
Non-binary

T-Shirt Size

Is this the first year your Camper has attended a Disciples church camp

What Congregation Do You Attend (choose from the dropdown menu)

PAYMENT: If you do not belong to a Disciples Church or if your church is NOT paying all of your fee, please pay using this link (please choose VA Region Camp Program or send a check to CCINVA, 1290 Enterprise Dr, Lynchburg, VA 24502 with memo stating which camp. https://www.ccinva.org/online-giving

Camper's Address

Camper's Email

Please provide the information below. If the address is the same as above for your camper there is no need to input again. WE MUST have an emergency phone number for the primary parent/guardian.

Parent/Guardian Name

Mobile Phone Number

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Preferred Emergency Phone Number

Address

Emergency Contact

Emergency Contact Number

PICK UP PERMISSION

Who has permission to pick up camper OTHER than the parent or guardian listed on this registration form? Please list NAME & RELATIONSHIP to camper

INSURANCE INFORMATION

If your camper requires medical treatment while at camp, your family's or camper's health insurance information will be used at the hospital. Please provide that information below.

Policy Holder's name

Health Insurance Carrier or Plan Name

Policy or Group Number

Dental Insurance Carrier/Policy Number/Group Number/Telephone Number

CAMPER MEDICAL INFORMATION

This section helps our volunteer staff and medical personnel know your camper’s medical needs including:

Any medications your camper will take during camp.

Over-the-counter (OTC) medications allowed or not allowed for your camper.

Allergies, diet, nutrition and vaccinations.

Social and emotional health.

General health questions and any restrictions.

MEDICATIONS

“Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. All medications are collected, store, and distributed by either a volunteer adult with a health care background or by camp health care personnel. Turn in all medications at Registration to the Camp Nurse upon arrival at camp.

Please list ALL MEDICATIONS(including OTC or non-prescription drugs) taken routinely. Bring only enough medications to last the entire time at camp. Keep the medications in the original packaging/bottle that identifies the prescribing physician(if a prescription drug), the name of the medication, the dosage and frequency of administration.

Please check the appropriate box below to indicate IF your camper WILL or WILL NOT take medication during camp.

The camper will take daily medications while attending camp.

If Yes, Please List (in this order): Name of Medication/Dose/Reason for Taking/Time that it is taken/How it is taken(oral, injection, etc)

Please check ONLY the OTC(s) that you camper CAN HAVE:

List anything you think we should know

Name of Camper's Primary Doctor

Primary Doctor's Phone Number

Name of Dentist & telephone number

Medical History

Help our volunteers understand your Camper's medical history so they can better care for your camper.

Briefly describe any special food needs

BRIEFLY DESCRIBE WHAT THE CAMPER IS ALLERGIC TO, THE REACTION SEENS, AND HOW IT IS TREATED.

EPIPEN: Does any allergy require the use of an Epipen?

IMMUNIZATION/VACCINATION HISTORY: Are you up-to-date with the following:

Diptheria, tetanus, pertussis (Dtap or Tdap)
Tdap booster
Polio
MMR (Mumps, measles, Rubella)
Varicella (chicken pox)
Hepatitis A
Hepatitis B
Meningococcal meningitis(MCV4)

If Camper is NOT up-to-date: please explain

Date of last PHYSICAL Exam

Solcial/Emotional Health(check ALL that apply to your camper

Camper is emotionally & socially stable
Camper has been or is currently treated for ADD/ADHD/Autism Spectrum Disorder/ OCD/Bipolar/Schizophrenia/Dementia/Depression or Anxiety, etc
Camper has been or is currently treated for emotional or behavioral or developmental difficulties or an eating disorder
During the past 12 months, has the camper seen a professional to address mental/emotional health concerns?
Camper had a significant life event that continues to affect the camper's life.

Please provide a brief description for any item you checked:

Please provide any additional information about any item(s) you have checked

What have we forgotten to ask? If your explanation about your camper's health exceeded the space above, please provide additional information about the camper that you think is important or that may affect the camper's ability to fully participate in the camp program by emailing Sue Gordon, [email protected] or Mary Anstice, [email protected] or calling the Regional office 434-846-3400(Mary or Sue)

DEEMED MEDICAL CONSENT/PRIVACY STATEMENT: This is for the June 1, 2025 - August 10, 2025 Camping season

As a health care provider, we are required by Section 32.1-45.1 of the Code of Virginia, as amended, to give you the following notice:

-If one of our health care professionals, workers or employees should be directly exposed to your child’s blood or body fluids in a way that may transmit a disease, you will be asked to have your child’s blood tested for human immunodeficiency virus, Hepatitis B or C viruses. A physician or other health care provider will tell you and the exposed person the result of the test.

-If your child should be directly exposed to the blood or body fluids of one or our health care professionals, workers or employees in a way that may transmit a disease, that person’s blood will be tested for infection with human immunodeficiency virus, Hepatitis B or C viruses. A physician or other health care provider will tell you and the exposed person the result of the test.

By checking this box, I authorize the release of my child’s medical information by the Craig Springs Camp to authorized camp personnel to benefit the health, safety of my child and to the physician(s) named on the registration application, the EMS, and/or the hospital provider involved in the emergency care of my child. I have read the Deemed Medical Consent/privacy statement above and I understand it.*

Photography and Promotional Release Waiver:This is for the June 1, 2025 – August 10, 2025 Camping season.

I grant permission to the CCINVA and Craig Springs and Retreat Center, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at Virginia Camping Ministry events for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by the Christian Church (Disciples of Christ) in Virginia.

The Virginia Camping Ministry cannot fully regulate the use of photography. Please note that photographs taken of you or your child by other event attendees may be used in their personal social media, etc. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child's rights, and my family's rights to any and all compensation stemming from the use of these materials.

Please select the appropriate permission box below.

Your choice is your digital signature for permission to photograph or videotape.

Parent/Guardian Consent and Release: This is for the June 1, 2025 - August 10, 2025 camping season.

I voluntarily agree to assume all of the risks and accept sole responsibility for any injuries to my child, myself, and other family members (including, but not limited to, personal injury, disability, or death), illness, damage, losses, claims, liability, costs or expenses of any kind (collectively, "Claims"), that l, my child and our family may experience or incur in connection with my child's, my own, or my family’s attendance at any CCINVA Craig Springs Camp and Retreat Center camps and any other Virginia Camping Ministry events, mission trips, camps or trail camps.

On my behalf, and on behalf of my child and my family, I hereby release, covenant not to sue, discharge, and hold harmless the CCINVA, Craig Springs Camp, its employees, volunteers, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the CCINVA and Craig Springs Camp and Retreat Center, its employees, volunteers, agents, and representatives.

By checking this box, I/We state that I/We have read and agree to the Consent and Release Information above. Checking this box represents your digital signature and authorization. You cannot register for camp WITHOUT accepting the "Consent and Release" information.

Behavior Covenant: For all Who Attend CCINVA-Virginia Camping Ministry Events: This is for the June 1, 2025 - August 10, 2025 camping season.

The leadership of the Virginia Camping Ministry of the Christian Church (Disciples of Christ) in Virginia consistently strives to provide a safe, Christian environment at all events. The goal of each event is to create a true sense of Christian community where all individuals have the opportunity to feel God's love and grow spiritually. With this in mind, our community standards must be followed to create such an environment. They are as follows:

Firearms or weapons (including but not limited to: air rifles, paintball guns, fireworks, or knives) are not allowed.
The presence and use of alcohol, tobacco products, cannabis, or illegal drugs of any type are not permitted, and the use of such will result in the participant being sent home.
Prescription and OTC medications are to be given to the camp medical staff in the original labeled container with instructions.
Proper respect for other people and their beliefs, their possessions, and Craig Springs' property or other facilities we use should be shown at all times.
Proper attire (shirt, pants, and shoes) for the activity and community environment should be worn at all times.
Electronic devices including cell phones, iPods, etc. should not be used at times that disrupt an individual's involvement in the Christian community during the camp or retreat.

CCINVA is not responsible for lost, stolen or damaged valuables. The camp director(s) of the week is responsible for the enforcement of the community standards (with the assistance of the camp management and residential staff) for their particular camp or event. The camp management will assist in the enforcement of these rules at all other events.

In the interest of putting your child's safety and security first, Virginia Camping Ministry reserves the right to search participants' and staff members’ personal belongings and/or vehicles if there is a suspect illegal substances or weapons. If a search is conducted there will always be two adults present, and the camper/staff member being searched will be given the option to be present. All efforts to protect their privacy will be made.

By checking this box the camper and parent(s) provide their digital signature and agree to uphold the Behavior Covenant. You cannot register for camp, or mission trip experiences without agreeing to uphold the Behavior Convenant.

PAYMENT: If you do not belong to a Disciples Church or if your church is NOT paying all of your fee, please pay using this link (please choose VA Region Camp Program) or send a check to CCINVA, 1290 Enterprise Dr, Lynchburg, VA 24502 with memo stating which camp. https://www.ccinva.org/online-giving

Event Registration Software by RegFox

PARENT / GUARDIAN INFORMATION

CAMPER MEDICAL INFORMATION

Medical History